Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Are you at least 18 years of age?

Yes

Are you legally able to work on the U.S.?

Yes

Are you interested in working:

Full-Time

Part-Time

If part-time, specify days/hours:

Have you ever been convicted of a felony?

Yes

If yes, please explain when, where, and nature of offense:

Are there any felony charges pending against you now?

Yes

If so, please explain:

How did you hear about this opening?

Employment Information

Please list former Employers, their phone numbers, Dates of Employment, Job Titles and Duties, and Reasons for Leaving

References

Please do not list family or anyone living with you

High School Education

Name of School City Course of Study Did you graduate?

College/Post-Graduate

Name of School City Course of Study Did you graduate?

Business/Trade

Name of School City Course of Study Did you graduate?

Military Service

From/To: Duties: Branch: Rank:

Please indicate what training, qualitification, or skills you'd like to focus on/improve.

Applicant Certification and Agreement (READ CAREFULLY before signing).

I hereby certify that all statements on this employment application are made truthfully and without evasion, and further understand and agree that such statements may be investigated and if found to be false will be sufficient reason for not being employed or if employed may result in my dismissal. I authorize the references listed on this application and any prior employer, educational institution or any other persons or organizations to give the Mosaic Christian Community Development Association (known hereafter as "Mosaic" or "Mosaic CCDA") and its program and staff any and all information concerning my previous employment/educational accomplishments, disciplinary information or any other pertinent information they may have, personal or otherwise, and release all parties from all liabilities for any damage that may result from furnishing same to you. I hereby waive written notice that employment information is being any person or organizations. In accordance with ADA requirements, if I require an accommodation to perform my job, I must notify the Mosaic Administration of that need within 180 days after I knew or reasonably should have known that any accommodation was needed. Failure to do so will bar me from alleging that the Mosaic CCDA has not accommodated me as required. I hereby authorize Mosaic to secure a criminal conviction history from the appropriate law enforcement agency should Mosaic determine it to be necessary to do so.

If you agree, enter your full name.

Entering your name constitutes a legally binding signature.

Let’s do this together

Mosaic CCDA

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