Community Counseling Center

 
 
402 S. Silver Springs Road Cape Girardeau, MO 63703 (573) 334-1100 www.cccntr.com
  
     
 

Employment Application

  
     
  Community Counseling Center is an Equal Opportunity Employer. Race, color, religion, age, sex, disability, marital or veteran status, place of national origin and other categories protected by law are not factors in employment, promotion, compensation or working conditions.  
     
 
 
     
 
Personal (Please Print Plainly) Date__________________________________
   
Name________________________________

Address_______________________________

City/State____________________________

Telephone umber______________________

 SSN___________________________________

______________________________________

Zip Code______________________________

Message Number_______________________
   
 
  Have you ever worked for Community Counseling Center before?    Yes    No  
     
 
If yes,when?__________________________ Name Employed By_____________________
 
     
  Have you ever applied for a position at Community Counseling Center before? Yes    No  
     
  List any friends or relatives working for us________________________________________  
     
  Have you ever been convicted or pled guilty to a misdemeanor or felony charge which shall include any suspended imposition of sentence, any suspended execution of sentence or any period of probation or parole?    Yes    No  
     
  If yes, describe in full ________________________________________________________  
     
  (NOTE: Community Counseling Center conducts background checks on all new employees in accordance with Missouri law. No applicant will be denied employment solely on the grounds of a conviction of a criminal offense. The nature of the offense the date of the offense, the surrounding circumstances and the relevance of the offense to the position (s) applied for may, however, be considered.)  
     
  Position applying for__________________________________________________________  
     
  Full Time    Part Time    Temporary     
     
 
Minimum salary desired_________________ Date Available for Employment____________
 
     
  Are you able to perform the essential functions of the job you are applying for? Yes  No  
     
 

 

 

Educational Background

  
 
 
  
 
 

Name & Location of School

 Number of Years Completed Diploma or Degree Major Field of Study
High School

 

        
College

 

        
Business, Trade, Secretary, etc.

 

        
 
 

 

  
  Special Skills  
     
  Do you speak, write or understand any foreign languages? Yes   No  
     
  If yes, which language (s)? ____________________________________________  
 
   
 
  Are you registered or licensed for any profession, skill or trade?    Yes    No  
     
 
If yes,what?______________________ License No. _______________________
 
     
 
State_____________ Year Attained____________ Expiration Date___________
 
     
  Use the space below to summarize other relevant experience, skills and background.  
     
     
 

 

  
 

 

  
 

 

  
 

 

  
 

 

  
 

 

  
 

 

  

Employment History Please complete this section even if a resume is enclosed. List all employers, starting with the most recent. You do not need to list any employer beyond the four most recent. If previously employed under another name or maiden name, please indicate.
 
Name of Company
Name of Supervisor
Address
Telephone Number
Position and Duties
Dates of Employment
Starting Rate of Pay
 Ending Rate of Pay
Reason for Leaving
 
Name of Company
Name of Supervisor
Address
Telephone Number
Position and Duties
Dates of Employment
Starting Rate of Pay
 Ending Rate of Pay
Reason for Leaving
 
Name of Company
Name of Supervisor
Address
Telephone Number
Position and Duties
Dates of Employment
Starting Rate of Pay
 Ending Rate of Pay
Reason for Leaving
 
Name of Company
Name of Supervisor
Address
Telephone Number
Position and Duties
Dates of Employment
Starting Rate of Pay
 Ending Rate of Pay
Reason for Leaving
 
May we contact the employers listed above? Yes   No

If no, indicate which one(s) you do NOT wish us to contact ___________________

Have you ever been fired from a job or asked to resign? Yes   No

If yes, please explain__________________________________________________
 

Personal References (List 3 - excluding former employers or relatives)
 
Name & Occupation

Address

Phone
 
 
 
 
Person to be notified in case of an emergency
 
Name _________________________ Phone Number _____________________
 
 
I hereby certify that the facts set forth in the above employment application are true and complete to the best of my knowledge. I understand that if employed, falsified statements, misleading statements, or omissions on this application shall be considered sufficient cause for dismissal. I hereby authorize Community Counseling Center to thoroughly investigate my references, work records, education and other matters related to my suitability for employment and further, authorize my current and former employers to disclose to the company any and all letters, reports and other information pertaining to my employment with them, without giving me prior notice of such disclosure. In addition, I hereby release Community Counseling enter, my current and former employers, and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure.

I understand that nothing contained in the application or conveyed to me during any interview which may be granted is intended to create an employment contract, implied or explicit, between me and Community Counseling Center. In addition, I understand and agree that if I am employed, my employment relationship with Community Counseling Center is strictly voluntary and at our mutual will. I understand that if employed, my employment is for no definite period and may be terminate any time, with or without prior notice, with or without cause or reason, at the option of either myself or Community Counseling Center, and that no promise or representations contrary to the foregoing are binding on Community Counseling Center unless made in writing and signed jointly by the Executive Director and myself.
 
Signature of Applicant _______________________ Date ___________________