Application for Employment

Personal Information
Full Name
Date
Address
Phone
Are you at least 21 years old?
- Yes
- No
Are you authorized to work in the U.S. on an unrestricted basis?
- Yes
- No
Positions applied for:
When can you start?
How did you learn of this opening?
Have you worked here before?
- Yes
- No
If Yes, please list Employment Dates & Facility
Have you been told the essential functions of the job or have you been shown a copy of the job description listing the essential functions of the job?
- Yes
- No
Can you perform these essential functions with or without reasonable accommodation?
- Yes
- No
Are there any hours, shifts, or days that you cannot or will not work?
What location are you willing to work in?
- Macon County Only
- Jackson County Only
- Macon or Jackson Counties
Shift preferred:
- Part time
- Full time
Are you willing to work overtime as required?
- Yes
- No

APPLICANT’S CERTIFICATION AND AGREEMENT
I certify that the facts set forth in this Application for Employment are true and complete to the best of my knowledge. I understand that if I am employed, false statements, omissions or misrepr esentations may result in my dismissal. I authorize MCH to make an investigation of any of the facts set forth in this application, including references. By signing, I authorize MCH to check references. I understand that employment at MCH is "at will" wh ich means that either I or MCH can terminate the employment relationship at any time, with or without prior notice, and for any reason not prohibited by statute. All employment is continued on that basis. I understand that no supervisor, manager or executi ve of MCH, other than the Executive Director or Board has any authority to alter the foregoing. Failure to sign will be considered an incomplete application and will not be considered.
- I agree to the above APPLICANT’S CERTIFICATION AND AGREEMENT

Personal Reference 1 : Family Member
Name
Address
Daytime telephone number
Personal Reference 2 : Non - Family Member
Name
Address
Daytime telephone number
Work Reference 1: Please use a supervisor or manager only
Name
Address
Daytime telephone number
Work Reference 2: Please use a supervisor or manager only
Name
Address
Daytime telephone number
INFORMATION RELEASE AUTHORIZATION
I authorize all corporations, former employers, personal references, credit agencies, educational institutions to release information about my background including, b ut not limited to information about my employment, education, and general public records history to MCH. This releases the aforesaid parties from any liability and responsibility for collecting the above information.
- I agree to the above INFORMATION RELEASE AUTHORIZATION

Macon Citizens Habilities, Inc.