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Business Office

101 2nd St., P O Box 12
Point Pleasant, WV 25550
Phone: (304) 675-2369

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Job Application Form

Mason County Action Group Job Application Form

Step 1 of 5

20%

Applicant Information
Date*
MM slash DD slash YYYY
Name*
First Middle Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
Date Available*
MM slash DD slash YYYY
Position Applied for*
Are you legally eligible to work in the U.S.?*
- Yes
- No
Have you ever worked for this company?*
- Yes
- No
When?*
Have you ever been convicted of a felony?*
- Yes
- No
Please explain:*

Education
High School Name
High School Address
High School Dates
From To
Did you graduate High School?
- Yes
- No
College Name
College Address
College Dates
From To
Did you graduate College?
- Yes
- No
Other Education Name
Other Education Address
Other Education Dates
From To
Did you graduate?
- Yes
- No

Employment History
Company
Employment Dates
From To
Company Address
Company Phone #
Supervisor
Responsibilities
May we contact?
- Yes
- No
Company
Employment Dates
From To
Company Address
Company Phone #
Supervisor
Responsibilities
May we contact?
- Yes
- No
Company
Employment Dates
From To
Company Address
Company Phone #
Supervisor
Responsibilities
May we contact?
- Yes
- No

References
List three references*
Full Name Relationship Company Phone # Address

Disclaimer and Signature
I certify that the information contained in this application is correct to the best of my knowledge. I understand that to falsify information is grounds for refusing to hire me, or for discharge should I be hired.

I authorize any person, organization or company listed on this application to furnish you any and all information concerning my previous employment, education and qualifications for employment. I also authorize you to re- quest and receive such information.

In consideration for my employment, I agree to abide by the rules and regulations of the company, which rules may be changed, withdrawn, added or interpreted at any time, at the company’s sole option and without prior notice to me.

I also acknowledge that my employment may be terminated, or any offer or acceptance of employment with- drawn, at any time, with or without cause, and with or without prior notice at the option of the company or myself.
Signature*
Date*
MM slash DD slash YYYY

Mason County Action Group is a non-profit organization dedicated to promoting independence and well-being for the senior citizens of Mason County, WV.

Mason County Action Group, Inc.
Business Office

101 2nd St., P O Box 12
Point Pleasant, WV 25550
Phone: (304) 675-2369

Gene Salem Senior Center

101 2nd Street
Point Pleasant, WV 25550
Phone: (304) 675-2369
Fax: (304) 675-2069

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