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Applicant Information

Name:      First Last M.I.
Address:   Street Apartment/Unit #
               City State Zip

Phone: E-Mail:
Date Available: Social Security No: Desired Salary: $ Position Applied for:

Are you a citizen of the United States?  
    If no, are you authorized to work in the United States?  
Have you ever worked for this company?  
    If yes, when?  
Have you ever been convicted of a felony?  
Do you have a valid driver's License?  
Can you lift 50 lbs.?  
Are you at least 18 years old?  
Will you work overnights and weekends?  
Do you have family employed by CCI?  
How did you hear about this job?

Education

High School: Address:
      From: To: Did you graduate? Yes   Diploma:

College: Address:
      From: To: Did you graduate? Yes     Degree:

Other: Address:
      From: To: Did you graduate? Yes     Degree:

References

Pease list three professional references.

Full Name: Relationship:
Company:        Phone:
Address:

Full Name: Relationship:
Company:        Phone:
Address:

Full Name: Relationship:
Company:        Phone:
Address:

Previous Employment

Company:        Phone:
Address:   Supervisor: Job Title:   Starting Salary: $  Ending Salary: $ Responsibilities: From: To: Reason for Leaving: May we contact your previous supervisor for a reference? Yes No

Company:        Phone:
Address:   Supervisor: Job Title:   Starting Salary: $  Ending Salary: $ Responsibilities: From: To: Reason for Leaving: May we contact your previous supervisor for a reference? Yes No

Military Service

Branch: From: To:
Rank at Discharge: Type of Discharge:
If other than honorable, explain:

Disclaimer and Digital Signature

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

If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.


    Type full name for digital signature

Criminal History- Community Connections Inc. requires a background check, including Criminal history, and Motor vehicle record check on all potential employees. I acknowledge and hereby give my consent to this procedure which can include taking my fingerprints.

    Type full name for digital signature

Drug Testing- In accordance with the South Dakota Codified Law (SDCL) 27B-1, Community Connections Inc. Requires all new employees to submit to drug testing as a pre-qualifying condition of employment.

    Type full name for digital signature


After sucessful submission, you will be returned to the homepage.

 

 

This institution is an equal opportunity provider and employer.


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