LIMA/ALLEN COUNCIL ON COMMUNITY AFFAIRS (LACCA)

540 South Central Avenue
Lima, Ohio 45804
Phone: 419-227-2586 ~ Website: www.lacca.org

Application for Employment

Thank you for your interest in LACCA. In order to have your application processed, you must thoroughly answer all questions on the application form. Applications filled out incompletely will not be considered. While we encourage you to attach a resume, please note that a resume will not substitute for completing any portion of this application. All information will be treated confidentially.

Last Name:
First Name:
Middle Initial:
Social Security # (Optional):
Address:
Home Telephone:

Work Telephone:
City:
State:
Zip Code:
Position Desired:
Salary Desired:

Date available to work:
Available:
 Full-Time   Part-Time
 Days            Evening
Have you previously applied for employment at LACCA?    Yes    No
If yes:
Month    Year 		Have you been previously employed by LACCA?
If yes
from to 		Have you ever been convicted for any offense other than a traffic violation?
 Yes    No
Are you a citizen of the U.S. or legal U.S. resident?  Yes    No
If no, do you intend to become one?
 Yes    No 		Referral Source:
 Employee Referral    Newspaper Advertisement
 Walk-in                       Internet
 Employment Agency    Other:

Special training or skills (language, computer operation, etc.) - Check skills/equipment operated:
 Computer       Fax                  Microsoft Word                  Other: 
 Typewriter     Cell Phone     Microsoft Excel   
 Internet          Website           Microsoft Power Point   
                                                             Microsoft Access

Have you any physical limitations that will prevent you from performing certain duties required for the position applied for?          Yes   No
If yes, please explain and recommend type of accommodations needed:

EDUCATION
Name & Location (Address, City & State, Zip Code)
LAST YEAR COMPLETED
1     2     3     4
COURSE OF STUDY
DEGREE
OBTAINED
HIGH
SCHOOL
COLLEGE
OTHER
RELATED
MILITARY
TRAINING

EMPLOYMENT HISTORY / REFERENCES

Employer

Address    		Dates Employed:
From
To       		Salary:
Start
Last    		Reason for leaving:
Phone  
Supervisor's Name
Your Job Title   		Work Performed:

Employer

Address    		Dates Employed:
From
To       		Salary:
Start
Last    		Reason for leaving:
Phone  
Supervisor's Name
Your Job Title   		Work Performed:

Employer

Address    		Dates Employed:
From
To       		Salary:
Start
Last    		Reason for leaving:
Phone  
Supervisor's Name
Your Job Title   		Work Performed:

REFERENCES

Please list three (3) additional references in addition to current/former employers (not relatives):
NAME
PHONE
ADDRESS, CITY, STATE, ZIP CODE
RELATIONSHIP
YEARS
KNOWN
H
W
H
W
H
W

Related Volunteer Experience (Include dates):

RESUME ATTACHMENT

If you would like to attach your resume please click on the "Browse" button below and locate the Microsoft Word formatted resume on your computer.

Attachment:

APPLICANT'S STATEMENT

I certify that answers given herein are true and complete to the best of my knowledge.

I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

This application for employment shall be considered active for a period of time not to exceed 6 months. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an "at will" nature, which means that the Employee may resign at any time and the Employer may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.

I hereby understand that clicking the "Submit Application" button below constitutes an Electronic Signature which carries the full weight and implications of a hand written signature.