Employment Application

Position you are applying for*:
Your Information

At which branch are you applying? cmd or ctrl click to select multiple:

First Name*:

Last Name*:

Home Phone*:

Cell Phone:

Email*:

Address*:

Apt/Suite :

City*:

State*:

ZIP Code*:

How were you referred to the Clayton County Community Service Authority? ctrl or cmd + click to select multiple answers:

Employee referred by:

Have you ever been employed by the Clayton County Community Service Authority?*:

If yes enter dates:

Are you a current or former Head Start Parent?:

Are you legally eligible for employment in this country?*:

Have you failed to be re-employed, ever been involuntarily discharged or asked to resign a position?*:

If yes please provide dates and circumstances.:

Have you ever been convicted of a crime?:

If yes provide dates and circumstances.* Conviction will NOT necessarily be a bar to employment. Each instance and explanation will be considered in relation to theposition for which you are applying:

Educational Background* Please include schools attended, degree/diploma earned and field of study if applicable:

Employment History* Please list employer names, addresses, phone numbers, job title, immediate supervisor, and dates employed and reasons for leaving:

May we contact these employers?:

Certifications Please list certifications, special accomplishments, special trainings, etc.:

References* Please list name and telephone number of 3 references. Only 1 reference can be a personal reference.:

OTHER SKILLS, EDUCATION, AND/OR TRAINING THAT IS DIRECTLY RELATED TO THE POSITION YOU ARE APPLYING FOR, I.E. TRADE SCHOOL, ON-THE-JOB TRAINING PROGRAMS,VOLUNTEER EXPERIENCE, CERTIFICATES, LICENSES, COMPUTER COURSES, ETC. NOTE: CERTAIN POSITIONS IN THE HEAD START PROGRAM REQUIRES COPIES/ WRITTEN VERIFICATION OF CREDENTIAL / DEGREE
Please list other skills related to the position you are applying for:

IF YOU ARE APPLYING FOR ANY POSITION THAT REQUIRES DRIVING PLEASE FILL OUT THIS SECTION
Do you have a valid Georgia Drivers License?:

If yes, give license number:

How many reportable accidents have you had in the past 5 years?:

How many moving violations have you had in the past 5 years?:

NOTE: IF YOU ARE SELECTED FOR AN INTERVIEW, YOU WILL NEED TO BRING A COPY OF YOUR MOTOR VEHICLE REPORT THAT IS NO MORE THAN TWO WEEKS OLD.
What is your race/ethnicity? Please mark the one box that describes the race/ethnicity category with which you primarily identify.These questions are processed and maintained separately from your personnel file and is not used to make decisions about the terms and conditions ofemployment. Completion of this form is optional and voluntary. We appreciate your assistance.
Hispanic or Latino a person of Cuban, Mexican, Chicano, Puerto Rican, South or Central American, or other Spanish culture or origin,:
White a person having origins in any of the original peoples of Europe, the Middle East, or North Africa
Black or African American a person having origins in any of the black racial groups of Africa.
Asian a person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinentincluding, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan,the Philippine Islands, Thailand, and Vietnam.
Native Hawaiian or Other Pacific Islander: a person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
American Indian or Alaska Native a person having origins in any of the original peoples of North and SouthAmerica including CentralAmerica, and who maintains tribal affiliation or community attachment.:
Two or More Races a person who primarily identifies with two or more of the above race/ethnicity categories.
EMPLOYEE NOTIFICATION OF CRIMINAL HISTORY RECORDS CHECKS AND FINGERPRINTING REQUIREMENT HEAD START AND PRE-K PROGRAM: I understand that criminal historyrecords checks and/ fingerprinting are required by law for employment with the program. Provisionary employment shall be offered based on the results obtainedfrom the local police department, but the agency will submit an application for you to the DECAL Fingerprint within 21 days of hire. Upon notification by theGCIC and DECAL that an individual has been convicted of any crimes prohibiting employment or contract status with the agency, the Executive Director ordesignee shall terminate that employment or contract status immediately. ALL OTHER PROGRAMS: I understand that criminal history records checks and/orfingerprinting are required by law. Employment shall be offered based on the result obtained from the local police department, but the agency will conductfurther criminal background check where necessary and you will be subjected to fingerprint collection. Upon notification by the GBI/FBI that an individual hasbeen convicted of any crimes prohibiting employment or contract status with the agency, the Executive Director or designee, shall terminate that employment orcontract status immediately. I understand that an individual so terminated may appeal action taken by the agency as a result of such checks in accordance withprocedures established by law, Rights for Review and Contested Case Hearings. Applicable appeal rights will be provided by the agency upon such terminationfrom agency employment or contract status. Any fees associated with criminal history records checks shall be paid by the agency.
Do you agree to the Criminal History Records Check and Fingerprint Requirements?:

EMPLOYMENT DECLARATIONI certify all information given on this application and any supporting information is true and complete and I authorize a complete investigation.I also certify that I have never been shown by credible evidence through court, jury, a department of investigation or other reliable evidence to have abused,neglected or deprived a child or adult, or subjected any person to serious injury as a result of intentional or grossly negligent misconduct as evidenced byoral or written statement to this effect obtained at the time of application.I agree that, if hired, I may be discharged if Clayton County Community Services Authority, Inc. at any time learns of any falsification regarding myqualifications or material omission in the information I have provided and if discovered prior to hire, I would be ineligible for consideration for not onlythis position but future positions as well.I authorize Clayton County Community Services Authority, Inc. to contact all former and current employer references and all educational institutions listed.All references are authorized to release all information requested which they might have about me.I hereby release Clayton County Community Services Authority, Inc. and all references from any liability which might be claimed because of information providedby such references.I agree that, if hired, I will follow all agency policies, rules, procedures and all other directions. I understand I may terminate my employment at any timeand for any reason without prior notice.I agree that if I am hired, I will be employed at the will of the agency and my employment can be terminated at any time, with or without notice.I understand Clayton County Community Services Authority, Inc. prohibits the possession or use of weapons, drugs, alcohol, and smoking on company property. Itis the policy of this agency to maintain a workplace safe and free of violence.I understand Clayton County Community Services Authority, Inc. is committed to promoting safety and high standards of employee performance, productivity andreliability. In order to achieve this, all finalists may be subject to a drug test prior to being hired to assure the agency that the applicant does notcurrently have narcotics, sedatives, stimulants, and other controlled substances and/or mood-altering substances in their body.I understand if I have any such substance in my body at the time of the drug test, Clayton County Community Services Authority, Inc. will not hire me. Ifurther understand that at any time during my employment with this agency my supervisor or Executive Director may require, as a term and condition of continuedemployment, a drug test if they have a reasonable suspicion that I am under the influence of any substance that might result in harm to myself or to others, orif I am involved in a preventable vehicle accident while doing agency business. I further agree to undergo a physical examination, at Clayton County CommunityServices Authority, Inc. expense, at any time the company makes such a request.I further understand that I have read the job description for the position for which I am applying, in all respect will be able to adequately perform theduties described, and that if I am selected as a finalist for any position with Clayton County Community Services Authority, Inc., they will do aninvestigation of criminal convictions.NOTE: You will not be automatically excluded from consideration if you have been convicted of a crime. Your suitability for the position sought will beevaluated based upon the totality of circumstances, such as: the nature of the crime, the recency of the conviction, the type of work involved, etc..I understand the agency reserves the right to add to, change and/or delete their policies, procedures, work rules and benefits at any time and that no one atClayton County Community Services Authority, Inc. has the authority to enter into any agreement, for any particular period of time, or contrary to the aboveterms, unless that agreement is set forth in writing and signed by the Executive Director.Under the Americans with Disabilities Act of 1991, this program is required to reasonably accommodate individuals with a disability.The reasonable accommodation requirement applies to the application process, any pre-employment testing, interviews and actual employment, but only if theprogram supervisor is made aware that an accommodation is required.If you are disabled and require accommodation, you may request it at any time during the interview process.You are obligated to inform the program director of your needs if it will impact your ability to perform the job for which you are applying.
You must agree to the above Employment Declaration:

AN EQUAL OPPORTUNITY EMPLOYER The Clayton County Community Service Authority is an equal opportunity employer and affords equal opportunity to all applicants for all positions without regard to race, color, religion, gender, national origin, age, disability, veteran status or any other status protected under local, state or federal laws.
By checking this box you agree to use this as your electronic signature, and you are confirming you have read, understand, and agree to the above. The information youprovided is true and accurate.:

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Employment Application

Your Information

AN EQUAL OPPORTUNITY EMPLOYER

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