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APPLICATION FOR EMPLOYMENT

LCCAA is an Equal Opportunity Employer

APPLICANT INFORMATION Last Name: First Name: MI: Date:

Address (Street, City, State, Zip Code):

Phone Number: Alternate Phone Number: E-mail Address:

Please list any other legal names and/or aliases:

POSITION INFORMATION Position(s) applying for: 1. 2.

May we refer your application within the agency for other positions which you may qualify for? Yes No

Available start date: Available weekends if required: Yes No Available to work overtime: Yes No

Have you been employed by LCCAA? Yes No If yes, list dates, locations, and departments:

Are you related to anyone currently employed by Lake Cumberland Community Action OR currently serving on the Board of Directors or Policy Council? Yes No List Name and relationship:

Have you served in the Armed Forces? Yes No If yes, dates of service:

Have you lived outside of the state of Kentucky in the last five years? Yes No

Are you authorized to work in the U.S.? Yes No If employed, you must show documents that prove your identity and employment eligibility as required by the Immigration Reform and Control Act of 1986.

Do you have a valid drivers license? Yes No Do you have a reliable means of transportation? Yes No

How did you find out about this job opening? LCCAA Web Site Human Resource Office LCCAA Employee Newspaper (Identify): Other (Please Explain):

EDUCATION Name and Location of School Number of Years

Completed

Diploma, Degree, or Certificate

-Attach Official Transcript(s)-Course of Study

High School

College/University

Other

Other

Other

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EMPLOYMENT HISTORY Dates Employed (Month/Year):

to Position Title:

Salary

Start: $ Final: $

Organization Name and Address:

Full-time Part-time May we contact this employer for references? Yes No

Supervisor’s Name/Title: Supervisor’s Phone:

Duties:

Reason for leaving:

Dates Employed (Month/Year): to

Position Title:

Salary

Start: $ Final: $

Organization Name and Address:

Full-time Part-time May we contact this employer for references? Yes No

Supervisor’s Name/Title: Supervisor’s Phone:

Duties:

Reason for leaving:

Dates Employed (Month/Year): to

Position Title:

Salary

Start: $ Final: $

Organization Name and Address:

Full-time Part-time May we contact this employer for references? Yes No

Supervisor’s Name/Title: Supervisor’s Phone:

Duties:

Reason for leaving:

Dates Employed (Month/Year): to

Position Title:

Salary

Start: $ Final: $

Organization Name and Address:

Full-time Part-time May we contact this employer for references? Yes No

Supervisor’s Name/Title: Supervisor’s Phone:

Duties:

Reason for leaving:

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REFERENCESPlease list at least three professional references. Please do not list any references included in the Employment History section above.

Name Address Phone Number

QUALIFICATIONS

Please use the space below to add any additional knowledge, skills, etc., to describe your qualifications.

SIGNATURE - Please read and sign the following statement: I certify that the information given in this application is correct and complete to the best of my knowledge. I am aware that, should investigation at any time show falsification, I will not be considered for employment or, if employed, I may be dismissed and disqualified from future employment. I hereby authorize this Agency to whom my name is certified/referred to make all necessary investigations concerning me, my work habits, character, or my action in any transaction. I understand and agree that I will be required to ratify the information contained in this application by signature as a condition of employment. I also understand that this Agency is a drug free workplace and that substance abuse testing is required.

APPLICANT’S SIGNATURE: DATE:

Mailing: PO Box 830, Jamestown, KY 42629 Physical: 23 Industry Drive, Jamestown, KY 42629

Email: apply@lc-caa.org Phone: (270) 343-4600 Fax: (270) 343-2800

April 27, 2018

Yes No Have you ever been convicted of violating any law (omit minor traffic violations)? If yes, list conviction(s), date(s), and place(s). Conviction is not an automatic rejection.

Applicant Affirmative Action Program Self-Identification Form

Required Information

Name:__________________________________Date of Application:_________________

Position(s) for which you are applying:_________________________________________

Voluntary Information

Lake Cumberland Community Action Agency is a government contractor and to comply with the regulations for equal employment opportunity and affirmative action (EEO/AA), we must track our applicants by gender and race/ethnicity and for the position they applied for to the government. We are an organization that values diversity and encourages women and minorities to apply. For this reason, we invite you to indicate your gender and race/ethnicity below. This information is kept separate from your application.

Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. Responses will remain confidential within the Human Resources Department; and will be used only for the necessary information to include in our Affirmative Action Program and reporting requirements to the government. When reported, data will not identify any specific individuals.

Gender: Male Female

Definitions of race/ethnicity are on the next page (as defined by the Equal Employment Opportunity Commission).

Race/Ethnic Identification (check one): Are you Hispanic or Latino? Yes No

If you answered “Yes”, you have completed this form and may stop here. If you answered “No” please select a race from the options below.

White American Indian or Alaska Native

Black or African American Two or more races

Native Hawaiian or Other Pacific I do not wish to disclose Islander

Asian

Definitions of Race/Ethnic Categories

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) – A person having origins in any of the original peoples of Europe, the Middle East, or North Africa

Black or African American (Not Hispanic or Latino)- A person having origins in any of the black racial groups of Africa

Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) – A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands

Asian (Not Hispanic or Latino) – A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam

American Indian or Alaska Native (Not Hispanic or Latino) – A person having origins in any of the original peoples of North and South America (including Central American), and who maintains tribal affiliation or community attachment

Two or More Races (Not Hispanic or Latino) – All persons who identify with more than one of the above five races