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Community Action, Inc. Application for Employment

Directions:
1. Conditions of application for employment are stated at the end of this form. Please read those conditions carefully before you sign this application.
2. Each section of this application must be completed in full, even if it is accompanied by a resume.
3. Submitting a resume along with this application is strongly recommended.
4. Assistance with completing this form is available upon request.
5. Please type all responses clearly and accurately.
6. An application must be completed for each position to which an applicant applies.
CAI, Inc. is an Equal Opportunity Employer Community Action, Inc.
3 Washington Square 4th Floor, Haverhill, MA 0180

Position Applying for:

Name

First Name

Middle Name

Last Name

Street Address

City

State

Zip

Phone Number

Email Address

Are you currently employed by CAI?

Yes

Have you ever been employed by CAI?

Yes

If yes to either question above, please complete the following information: Position/Start-End Date/Reason for Leaving below:

Please disclose the names of any immediate family members including spouse, parent, child, or sibling who are current CAI employees. CAI will not allow an immediate family member to directly supervise another family member.

Family Member Name

Relation To You

Family Member’s Position at CAI

Please list days and hours you are available to work:

Are you at least 18 years of age?

Yes

Are you legally eligible to work in the United States, and can you submit verification of your legal right to work in the United States upon being offered a position?

Yes

Employment History
• Please begin with your most recent employment and continue will all past employment.
• Employment History section must be completed in full even if your resume is submitted.
• Applicants may include verifiable work performed on a volunteer basis.

Most Recent Employer

Position Held

Dates Employed

Please Use Format dd/mm/yy-dd/mm/yy

Employer’s Complete Address

Job Duties

Reason For Leaving:

Supervisor’s Name

Employer’s Telephone Number

May We Contact This Employer

Yes

2nd Most Recent Employer

Position Held

Dates Employed

Please Use Format dd/mm/yy-dd/mm/yy

Employer’s Complete Address

Job Duties

Reason For Leaving:

Supervisor’s Name

Employer’s Telephone Number

May We Contact This Employer

Yes

3rd Most Recent Employer

Position Held

Dates Employed

Please Use Format dd/mm/yy-dd/mm/yy

Employer’s Complete Address

Job Duties

Reason For Leaving:

Supervisor’s Name

Employer’s Telephone Number

May We Contact This Employer

Yes

4th Most Recent Employer

Position Held

Dates Employed

Please Use Format dd/mm/yy-dd/mm/yy

Employer’s Complete Address

Job Duties

Reason For Leaving:

Supervisor’s Name

Employer’s Telephone Number

May We Contact This Employer

Yes

Education & Skills

All Applicants:

If you are selected for a position with minimum educational requirements or specific certifications, a copy of your transcripts, diploma, HISET (Formerly known as a GED) or certifications will be required prior to employment.

Did you graduate from High School?

Yes

If not, have you obtained a HISET (Formerly known as a GED)?

Yes

Please list any colleges or technical schools you have attended (Name/Address/Subject Studied/Degree and/or Certificate):

Please list any other training or skills, including computer or language skills that are relevant to this position:

Early Childhood Education Applicants:

Do you have a Child Development Associates Certificate (CDA)?

Yes

Do you have a Department of Early Education and Care (EEC) license?

Yes

If so, check all that apply

Lead Teacher

Director 1

Director 2

List recent Continuing Education Units (CEUs), trainings or other education:

Driver’s License Information

Do you have a valid driver’s license?

Yes

Do you have a valid bus driver’s license?

Yes

If so, which state?

Class

Endorsements

Professional References

List at least two people not related to you who can comment on your work performance.

Make sure to add valid contact information

Statement Of Interest

Please tell us about your interest in this position and what you think you would be able to contribute to CAI:

Upload Your Resume

Maximum file size: 268.44MB

Notification & Agreement

All of the information that I have provided on this application is accurate to the best of my knowledge. I authorize Community Action, Inc. to make inquiries to determine my suitability for employment. In signing this application, I understand that my previous and present employers may be asked for information relative to my employment record with them. Further, I understand a Background Records Check may be completed prior to employment. An additional release for the Background Records Check will be provided as part of the application process. I understand applicants for all positions within the Early Childhood Development Program who have direct contact with children are required to undergo a post-offer, pre-employment medical examination to be conducted by a physician designated or approved by CAI. Any conditional offer of employment that an Early Childhood Development Program applicant receives from CAI is contingent upon, among other things, satisfactory completion of this examination and screening and a determination by CAI and its examining physicians that the applicant is capable of performing the essential functions of the position that has been offered, with or without reasonable accommodation. It is the policy of CAI, to afford equal opportunity to all employees and applicants without regard to age, race, religion, color, sex, national origin, marital status, expunged juvenile records, pregnancy, sexual orientation, ancestry, or genetic information; and afford equal opportunities to disabled veterans of the Vietnam era and to individuals with a disability or any other characteristic protected by Federal, State or Local Law. I fully understand and agree that any section left incomplete on this application; any false, inaccurate and/or misleading statements made by me on this application or by me failure to answer any applicable questions on the application; false, misleading, or inaccurate information contained on the certificates, documents, or other papers which may accompany this application (i.e. misrepresentation of prior employment, education, or training); or any false, misleading or inaccurate information provided during the entire selection process will be sufficient to cause for my application being rejected or for my discharge from CAI at any time after employment. Please recheck your application and make sure that all questions are answered correctly prior to signing. The application will be given every consideration, but its receipt does not imply that the applicant will be employed.

I agree to the terms.

Electronic Signature

Your name here signifies you accept your typed name as your signature

Date

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