Advantages of an Employment Application

							                                                   Council on Aging Learning Advantages
                                                   (COALASM)
                                                   Area Agency on Aging Region#9, Inc
                                                   60788 Southgate Road
                                                   Byesville, Ohio 43723
                                                   (740)432-6600 ext. 313
                                                   email: nshambaugh@aaa9.org



                                             DATE: ___________________________________________


                    APPLICATION FOR ADMISSION
                                           PERSONAL
                                           (PLEASE PRINT)

NAME
              LAST                         FIRST                                           MIDDLE

ADDRESS
              NO.          STREET              Apt. No.            CITY               STATE       ZIP

PHONE NO: HOME (_____) ____________________________

              WORK (       ) ____________________________

              CELL (_____) _____________________________

SOCIAL SECURITY NO. _______________________________________

E-MAIL ADDRESS: ____________________________________________

EMERGENCY CONTACT (NEXT OF KIN OR FRIEND):

NAME/RELATIONSHIP:_______________________________________ PHONE: ____________________

NAME/RELATIONSHIP:_______________________________________ PHONE: ____________________
                              EDUCATIONAL BACKGROUND
       NAME AND LOCATION                   GRADUATE        DEGREE OR FIELD OF STUDY    CURRENTLY ENROLLED
                                           YES   NO                                         PT       FT

HIGH SCHOOL                            |       |       |                                   |      |
                                       |       |       |                                   |      |
                                       |       |       |                                   |      |
BUSINESS                               |       |       |                                   |      |
OR TRADE                               |       |       |                                   |      |
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PLEASE COMPLETE THE FOLLOWING IF YOU WERE EVER CONVICTED OF A CRIME. IF
NONE, SO STATE. (Additional space provided on last page, if necessary.)
       DATE OF
      CONVICTION
                        CITY AND STATE                        CHARGE                         DISPOSITION
      MONTH &
       YEAR
 1.

 2.

 3.


 ______ Never Convicted of any crime

                                         PREVIOUS ADDRESSES
      PLEASE LIST ADDRESSES WHERE YOU HAVE LIVED IN THE LAST FIVE (5) YEARS, OR
                 YOUR LAST THREE (3) ADDRESSES, WHICHEVER IS MORE.

ADDRESS____________________________________________________________________________________________________________

CITY________________________________________________STATE________________________________ZIP_______________________

COUNTY____________________________________________

HOW LONG WERE YOU AT THIS ADDRESS_____________________YEARS________________________MONTHS


ADDRESS____________________________________________________________________________________________________________

CITY________________________________________________STATE________________________________ZIP_______________________

COUNTY____________________________________________

HOW LONG WERE YOU AT THIS ADDRESS_____________________YEARS________________________MONTHS


ADDRESS____________________________________________________________________________________________________________

CITY________________________________________________STATE________________________________ZIP_______________________

COUNTY____________________________________________

HOW LONG WERE YOU AT THIS ADDRESS_____________________YEARS________________________MONTHS




                                              EMPLOYMENT
Are you currently employed? ____ yes ___no

If yes, Where? __________________________________________________________________________________________________

If no, for how long? _____________________________________________________________________

Comments:


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           PLEASE READ CAREFULLY BEFORE SIGNING YOUR SIGNATURE
I agree that all the above statements are true to the best of my knowledge.

It is understood and agreed upon that any misrepresentation by me on this application will be sufficient
cause for cancellation and/or separation from the Council on Aging Learning Advantages program.

I am aware that I may be asked to submit to tests for the illegal use of drugs as a condition of my
employment after graduation from the Council on Aging Learning Advantage program. I understand
that failure to pass such tests may be grounds for denial of employment or termination, if employed at
the time.

Council on Aging Learning Advantages does not discriminate in admissions and no question on this
application is used for the purpose of limiting or excusing any applicant’s consideration for admission
on a basis prohibited by local, state or federal law.



Signature of Applicant                                                  Date




Revised 061103




                                                    3
                                  COALASM APPLICANT FLOW DATA




                                  Name: ______________________________________________

                                    Date: ______________________________________


Please circle as appropriate:

Sex:                    Male              Female


Race/Ethnic Status:     White                                Hispanic
                        African American                     American Indian/Native Alaskan
                        Asian/Pacific Islander               Other


Over 40:                Yes               No


Veteran Status: (circle all that apply)

I am a Veteran          I am a Vietnam Era Veteran           I am a disabled veteran


Disability Status:      I am a person with a disability. If so, check here


How did you learn about us? Friend                 Walk-in            Relative

                                Job FairInternet             Agency

                                Radio              Television         Newspaper/Publication

                                Former Student

                                Other___________________________


The Council on Aging Learning Advantages Program will not discriminate against any applicant with regard to
race, color, religion, sex, age, veteran status, national origin or disability.




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                                               Council on Aging
                                             Learning Advantages
                                                     COALASM




                             COALASM Information Release Form


“In consideration of my participation in the COALA program I, _______________
_______________, hereby authorize and request COALA to provide and release any
personal and Home Health Aide/Homemaker training information about me that may be
sought by prospective employers and/or COALA contracted services and I hereby release
COALA and its agents from any and all liability for providing or releasing such
information and waive any privileges involved.”

I understand that by law, COALA must release information with or without my consent
in the following situations: under court order; to report abuse; or to report if you are at
risk of harming yourself or others.

My signature indicates that I have read, understand and agree to this consent form.


Signature: ___________________________________________ Date:____________


Witness: _____________________________________________ Date: ___________




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     CONSUMER REPORTING AGENCY INFORMATION RELEASE FORM FOR CRIMINAL
                                 RECORDS

TO WHOM IT MAY CONCERN:

Council on Aging Learning Advantages (hereinafter COALA SM) has informed me, and I hereby
acknowledge, that it will obtain a criminal report on me for admission purposes. COALA has advised me
that before it takes any adverse action, based in whole or in part on the information obtained, that it will provide
me with a copy of the report and a written description of my rights.

I hereby authorize and request (in accordance with the attached “Background Check” form) all local, municipal,
city, county, state, and federal police/law enforcement authorities to furnish any information that may be sought
by COALA regarding any criminal conviction of mine.

I hereby release all parties from any liability for any damage that may result from furnishing any such
information and waive any privileges involved.


DATE: __________________          NAME(S)*:_________________________________________

                                               _________________________________________


                                   SIGNATURE: _____________________________________

                                   SSN:             _____________________________________

*If the records appear under more than one name, please provide all names.




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