Position Applied For:
Are you 18 or over?:
Are you authorized to work in the United States:
Last Name:
First Name:
Middle Name:
Email Address :
Address:
City, State:
Zip:
Home Phone:
Cell Phone:
Business Phone:
Are you related by blood or marriage to any person now working at Coastal Community Action, Inc.:
If yes, give name, relationship to you, and position:

Education

Select the highest grade completed
School:
College:
Graduate School:
Under S/Q Hrs., list the hours of credit received and it they were semester (S) or quarter (Q) hours

High School

Name and Location:
Grad?:

College/University

Name and Location:
Grad?:
S/Q Hrs:
Major/Minor Course Work:
Type of Degree Received:

Graduate or Professional

Name and Location:
Grad?:
S/Q Hrs.:
Major/Minor Course Work:
Type of Degree Received:

Early Childhood Education

Name and Location:
Grad?:
Major/Minor Course Work:
Type of Degree Received:

Special training programs and seminars you have completed in the last five years:
If the job(s) applied for calls for specific courses, indicate those courses taken and credits received:

Skills

Check the following skills, experiences, etc. which you have
Driver's License
Number:
State:
CDL
Number:
State:
Passenger bus endorsement
Car for use at work?
Foreign Language
Please specify:
Computer Experience
Please specify:
Word processing
Other:
Have you been convicted of a felony within the last 5 (five) years? (A conviction does not mean you cannot be hired. The offense and how recently you were convicted will be evaluated in relation to the job for which you are applying.):
If yes, please explain:

Work History

(include volunteer experience)

Employer 1

Current or Last Employer:
Address:
Job Title:
Supervisor's Name:
Phone Number:
Number supervised by you:
Date Employed (mo/yr):
Date Separated (mo/yr):
Starting Salary:
Ending or Current Salary:
Reason for Leaving:
May we Contact Employer:
Years/Months Working Full Time:
Years/Months Working Part Time:
If part time, number of hours worked per week:
List major duties in order of their importance in the job:

Employer 2

Employer:
Address:
Job Title:
Supervisor's Name:
Phone Number:
No. Supervised by you:
Date Employed (mo/yr):
Date Separated (mo/yr):
Starting Salary:
Ending or Current Salary:
Reason for Leaving:
Years/Months Working Full Time:
Years/Months Working Part Time:
If part time, number of hours worked per week:
List major duties in order of their importance in the job:

Employer 3

Employer:
Address:
Job Title:
Supervisor's Name:
Phone Number:
No. Supervised by you:
Date Employed (mo/yr):
Date Separated (mo/yr):
Starting Salary:
Ending or Current Salary:
Reason for Leaving:
If part time, number of hours worked per week:
List major duties in order of their importance in the job:

Employer 4

Employer:
Address:
Job Title:
Supervisor's Name:
Phone Number:
No. Supervised by you:
Date Employed (mo/yr):
Date Separated (mo/yr):
Starting Salary:
Ending/Current Salary:
Reason for Leaving:
Years/Months Working Full Time:
Years/Months Working Part Time :
If part time, number of hours worked per week:
List major duties in order of their importance in the job:

Affirmative Action Information ‐ Applicant Form

Coastal Community Action, Inc. (CCA) is committed to the concept of equal employment opportunity. Solely in order to help make this commitment a reality, CCA has established an affirmative action plan which includes asking its applicants to provide certain information on a voluntary basis. Providing any of the information requested below is entirely voluntary. Your decision whether or not to provide this information will not affect your employment candidacy with CCA or your status as an employee if appointed. CCA will keep the information you provide confidential, and will use the information only in accordance with the ADA and other applicable laws.

How did you learn of this job opening?:
Age:
Gender:
Race or Ethnic Group
HISPANIC or LATINO ‐ A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race
WHITE (Not Hispanic or Latino)
BLACK or AFRICAN AMERICAN (Not Hispanic or Latino)
NATIVE HAWAIIAN or OTHER PACIFIC ISLANDER
ASIAN (Not Hispanic or Latino)
AMERICAN INDIAN or ALASKAN NATIVE (Not Hispanic or Latino)
Are You Disabled:
(Disabled individual means any person who (1) has a physical or mental impairment which substantially limits one or more of such person’s major life activities; (2). has a No record of such impairment; or (3) is regarded as having such an impairment. A disabled individual is “substantially limited” with respect to the activity of employment if he or she is likely to experience difficulty in securing, retaining, or advancing in employment
CCA is firmly committed to carrying out laws which protect the disabled from discrimination. The agency’s policy is to ensure applicants for employment who are disabled have the same job opportunities as all others. Submission of information regarding disabled status is voluntary and refusal to provide it will not prejudice your chance of employment, nor subject you to discharge or disciplinary treatment if you are employed. Information obtained concerning individuals shall be kept confidential, except that if you are hired, supervisors and managers may be informed regarding restrictions on the work of duties of disabled individuals, and regarding necessary accommodations. First aid and safety personnel may be informed, when and to the extent appropriate, if the condition might require emergency treatment, and government officials investigating compliance with relevant laws shall be informed.
Upload Resume:
Signature of Applicant:
Date:
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A common thread through all of our services, be they Family Services, Senior Services, or Housing Services, is that we help change lives by providing needed resources and support. Coastal Community Action, Inc. provides needed services to thousands of residents in our region annually.