AmeriCorps Program Application

Please print this page and complete all sections of this application.  Please also provide a signature where requested.

 

Thank you for your interest in the CARITAS AmeriCorps program.   This is an AmeriCorps funded position.  AmeriCorps service is stipended volunteerism.  We are looking for individuals whose primary motivation for seeking the position is a desire to help the community and is not solely financial in nature.  AmeriCorps members receive a living allowance (or stipend) which is paid evenly over the service term and an education grant at the conclusion of your term of service.  All terms of service conclude on August 31.

Position Applied For: ___________________________________________

CARITAS is an Equal Opportunity Employer and does not discriminate against applicants or employees on the basis of race, color, religion, sex, national origin, age, disability, veteran status, or any other protected status as defined in local, state, or federal law. 

Personal Information

Name ___________________________________ _____________________________________ _______

Last                                                                        First                                                                        Initial

Address ______________________________________________________________________________

Street                                                                                      City                                        State       Zip

Telephone (          ) _______ – ___________                Social Security Number _______ – ____ – ________

 

Email address: _________________________________________________________________________

Circle Your Responses

Are you 18 years of age or older? Yes   No
Have you applied for a job with CARITAS in the past?    Yes   No Do you have a Driver’s License? Yes   No
Have you ever been terminated from employment? Yes   No

If so, please state the circumstances:

 

May we contact your current employer for information? Yes   No
Type of employment sought:
Full Time     Part Time     Temporary
When are you available to begin? _____________________
Will you provide proof of your legal work status when requested? Yes   No

Do you have any friends or relatives employed by CARITASYes   No

If so, who?

Have you ever worked for CARITAS before?  Yes   No          If so, when?

If you were offered a full time position elsewhere, would you accept it? Yes  No

 

At CARITAS, we view past barriers as stepping stones rather than barriers.  Have you ever been convicted of a crime?  Yes   No (not traffic violations)

If yes, please state the circumstances *:

                                                                                                                                                                                               

*NOTE: No applicant will be denied employment solely on the grounds of a conviction of a criminal offense.  The nature of the offense, the date of the offense, the surrounding circumstances and the relevance of the offense to the position(s) applied for may, however, be considered.

What days and hours can you work?  Anytime  Sunday  Monday  Tuesday  Wednesday Thursday  Friday  Saturday

 

Full disclosure of criminal activity: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

I, _____________________, give CARITAS permission to obtain a Criminal History Record/Sex Offender & Crimes Against Minors Registry Search (VA State Police form SP 230), State (sp – 167) and an FBI fingerprint background check as a condition of my employment with CARITAS.  I understand that this information will be maintained in my personnel file and will remain confidential.

 

Last Name ______________________                                          Date of Birth ___________

First Name ______________________                                         Soc. Security Number

Middle Name _____________________                                       ______________________

Maiden Name ____________________                                        Sex:        M            F

Race:      Asian/Pacific        Black     White     Indian/Alaskan     Other

Signature:__________________________________________________________

Date:___________________

 

Educational Background

(Begin with most recent)

Name and Address of School

 

 

Number
of Years Attended

Degree, Diploma,
or Certificate Attained
Major Field

Graduated?
Yes/No

 

                                                                               

 

                                                                               

 

 

                                                                               

 

                                                                               

 

 

                                                                               

 

                                                                               

 

Employment History

(Include all prior employment (even if you plan to attach your resume) and begin with most recent.)

Employer: ________________________________________________  Phone  (        ) _____ – ____________

Address _________________________________________________________________________________

Supervisor: __________________________                            Your Position/Duties: ____________________

_______________________________________________________________________________________

Type of Employment (FT/PT/Temp):                                                                                                                                

Reason for leaving: ________________________________________________________________________

Date Hired: _____________                            Starting Rate of Pay: _____________

Date Terminated: ___________                      Last Rate of Pay: _____________­___

 

Employer: ________________________________________________  Phone  (        ) _____ – ____________

Address _________________________________________________________________________________

Supervisor: __________________________                                Your Position/Duties: ____________________

______________________________________________________________________________________

Type of Employment (FT/PT/Temp):                                                                                                                                

Reason for leaving: ________________________________________________________________________

Date Hired: _____________                            Starting Rate of Pay: _____________

Date Terminated: ___________                      Last Rate of Pay: _____________­___

References

Name:                                                                                                   

Company:                                                                                            

Address:                                                                                               

Telephone Number:                                                                           

Number of Years Acquainted:                                                         

 

Name:                                                                                                   

Company:                                                                                            

Address:                                                                                               

Telephone Number:                                                                           

Number of Years Acquainted:                                                         

 

Name:                                                                                                   

Company:                                                                                            

Address:                                                                                               

Telephone Number:                                                                           

Number of Years Acquainted:                                                         

 

If referred by a current CARITAS employee, please provide the name of the employee: _             ______

Applicant’s Certification

I certify and affirm that the information provided by me during interviews, on this application and all other related documents to be true in all respects, and I further understand that any false or misleading statements or omissions, whenever discovered, will be grounds for immediate termination from further consideration or termination of employment.

I understand and agree that nothing in this Application or anything conveyed during any interviews is intended to create a contract for employment with CARITAS.  If employed by CARITAS, I agree to conform to the guidelines and policies of CARITAS.

I understand that I or CARITAS may terminate my employment at any time, with or without cause, and that any assurances of continued employment, whether written, oral or by conduct, shall not be interpreted as changing the “at will” nature of my employment relationship with CARITAS, unless specifically acknowledged in writing by an authorized officer of CARITAS.

I understand that if I am offered employment, I will be required to satisfy the requirements of the Immigration and Control Act by showing eligibility for legal employment in the U.S. within three (3) business days of the date employment begins.

I understand that CARITAS may conduct a routine background investigation in connection with my application for employment including but not limited to a criminal background check.

I authorize CARITAS to verify all references and information provided by my in this application.  I release CARITAS, and any person or company responding to any reference or request for information from any claim or liability regarding any information or opinion supplied.

I understand that this application is good for only sixty (60) days from today’s date.

_________________________                                                                             ___________________________

Applicant’s Signature                                                                                                         Date