Employee Information
Please Complete – Incomplete Applications Will Disqualify Candidates for Consideration. All Applicants are required to submit a resume with their application and must sign this application for consideration.
(We encourage U.S. Veterans, individuals with disabilities, and AmeriCorp applicants to apply.)
Last Name:
Click or tap here to enter / First Name:
Click or tap here to enter text. / Middle Name:
Click or tap here to enter
Mailing Address:
Click or tap here to enter text. / City:
Click or tap here to enter text. / State:
/ Zip Code:
Home Phone:
/ Cell Phone:
/ E-Mail Address:
Date of Application:
Click or tap to en a date. / Social Security No. (Optional):
Click or tap here to enter text. / Position Applying for:
Click or tap herenter text.
Are you legally eligible for employment in the USA? ☐Yes ☐No (If yes, verification will be required.)
I am seeking a position that is ☐Full-Time ☐Part-Time ☐Summers ☐Temporary
Are you under 18 years of age? ☐Yes ☐No (If yes, you will need to provide proof of eligibility to work.)
Are you able to perform the essential functions of the position with or without a reasonable accommodation? ☐ Yes ☐ No
We encourage former Head Start/Early Head Start/PAT (Parents as Teachers) & Child Development Center parents to apply with our Early Childhood programs.
Are you a parent of a current Head Start/Early Head Start parent or Early Childhood Program? ☐Yes ☐No
Have you even been the parent of a Head Start/Early Head Start or Early Childhood Program? ☐Yes ☐No
Shift Preference: ☐Days ☐Evenings ☐Nights ☐Weekends
Date you are available to begin work if offered the job: Click or tap to enter a date.
Do you have a valid driver’s license? ☐Yes ☐No
License # Expiration Date:
State issued in: Class:
Do you have any relatives working for RurAL CAP or any associated Subsidiary company? ☐Yes ☐No
(If yes, please list their full name(s), relationship (e.g., sister, father, aunt, etc.), and position(s) held.)
Have you ever worked for RurAL CAP or any associated Subsidiary company? ☐Yes ☐No
(If yes, please list the department, position held, dates employed, and why you want to return to work at RurAL CAP.)
Where did you first hear about the job for which you are applying?
☐Employee ☐Friend or Relative ☐RurAL CAP Website ☐Newspaper
☐Department of Labor
☐On-Line Job Posting (please specify):
☐Job Fair (please specify):
☐Other (please specify):
Have you ever been fired, discharged, asked to resign, furloughed, put on inactive status for cause, or subjected to disciplinary action while in any position (except military). ☐Yes ☐No If yes, state circumstances:
Have you ever resigned (quit) after being informed your employer intended to discharge (fire) you for any reason? ☐Yes ☐No (If yes, please explain, giving name and address.)
Have you ever been convicted of any violation of the law, other than for minor traffic violations?
☐Yes ☐No
If yes, please explain below with the date of conviction. Any DWI/DUI must be listed. Do not include those cases dismissed in your favor, juvenile delinquent, and youthful offender adjudications, sealed, or expunged convictions. (Disclosing information about convictions will not result in automatic disqualification for consideration for employment.)
Some positions require additional information on specific criminal activity. Please provide information, such as dates, charges, and disposition regarding all pending and prior criminal arrests and charges related to child sexual abuse, convictions related to other forms of child abuse and/or neglect, and convictions of violent felonies. A conviction record is not an automatic bar to employment. Each case will be considered regarding date, job relatedness, nature of the crime, and evidence or rehabilitation.
Employment History
List most recent employment first, including, summer and temporary jobs and all paid and unpaid work experiences. Be sure all your experiences or employers related to this job are listed here. Please include resume, or use an extra sheet of paper (attached to the Employment Application.) Explain any significant breaks in employment (i.e., six months or more.)
Employer:
/ Dates worked (Month/Year):
Start:
To: / May we contact the employer?
☐ Yes ☐No
Address:
/ Job Title:
/ Ending Salary:
Name of Supervisor:
/ Phone Number:
/ Email Address:
Description of Duties/Responsibilities (may substitute resume for this section):
Reason for Leaving:
Employer:
/ Dates worked (Month/Year):
Start:
To: / May we contact the employer?
☐ Yes ☐ No
Address:
/ Job Title:
/ Ending Salary:
Name of Supervisor:
/ Phone Number:
/ Email Address:
Description of Duties/Responsibilities (may substitute resume for this section):
Reason for Leaving:
Employer:
/ Dates worked (Month/Year):
Start:
To: / May we contact the employer?
☐ Yes ☐ No
Address:
/ Job Title:
/ Ending Salary:
Name of Supervisor:
/ Phone Number:
/ Email Address:
Description of Duties/Responsibilities (may substitute resume for this section):
Reason for Leaving:
Employer:
/ Dates worked (Month/Year):
Start:
To: / May we contact the employer?
☐ Yes ☐ No
Address:
/ Job Title:
/ Ending Salary:
Name of Supervisor:
/ Phone Number:
/ Email Address:
Description of Duties/Responsibilities (may substitute resume for this section):
Reason for Leaving:
Employer:
/ Dates worked (Month/Year):
Start: Click or tap to enter a date.
To: Click or tap to enter a date. / May we contact the employer?
☐ Yes ☐ No
Address:
/ Job Title:
/ Ending Salary:
Name of Supervisor:
/ Phone Number:
/ Email Address:
Description of Duties/Responsibilities (may substitute resume for this section):
Reason for Leaving:
Section Three - Licenses/Certifications/Skills
List any professional licenses, certifications, and/or registrations that would be relevant to the job for which you are applying. (Please include license number and expiration date, if applicable):
Additional skills including supervision skills, other languages, or information regarding the career/occupation you wish to bring to the employer’s attention:
Computer skills, including whether you are entry-level, advanced, or intermediate skill level on each skill.
(e.g. Advanced excel experience, intermediate word experience, entry-level outlook, etc.)
Section Four - Education
High School:
/ Location:
/ Graduate:
☐Yes ☐No / GED:
☐Yes ☐No
List information below for all colleges or universities attended. If offered a position, you will be required to provide certified transcripts for degree(s).
Name and Location of College or University: / Graduate: / Years Completed: / Degree Received/Course of Study
☐Yes ☐No
☐Yes ☐No
☐Yes ☐No
List any vocational, specialized, technical, or apprenticeship training, including any training, and duty while in military service.
Name and Location of School: / Dates Attended: / Course of Study: / Certificate or Diploma:
Describe all computer knowledge and skills.
Software: / Level of Expertise: (e.g., Beginner, Intermediate, Expert) / Years: / Hardware: / Level of Expertise: (e.g., Beginner, Intermediate, Expert) / Years:
List any professional, trade, or volunteer activities relevant to the job for which you are applying:
List the machinery or equipment, specific to the position, that you are qualified to operate or repair:
Operate:
Repair:
If you are applying for a construction and/or laborer position, please answer the following:
Do you have any construction experience: ☐ Yes ☐ No
Have you ever been a Foreman or a Crew Boss? ☐ Yes ☐ No
If yes, please list when and where.
In addition to your work history, what other experience, skills, or qualifications do you have which especially prepare you for the position for which you are applying (e.g., special projects, seminars, club activities, special honors, etc.)? Omit any information that discloses race, religion, color, national origin, age, physical or mental disability, gender, sexual orientation, marital status, changes in marital status, pregnancy, parenthood, or any other protected-class matter.
Section Five - References
Full Name: / Job Title: / Company: / Phone No.: / Email:
Branch of Service:
/ Dates Enlisted:
/ Date of Discharge:
Click or tap to enter a date. / Type of Discharge:
/ Supervisor:
Present Military Affiliation: / ☐ Active Reserve / ☐ Inactive Reserve / ☐ None / ☐Other
While in the military, were you ever charged or convicted of an offense that resulted in a trial by deck court or by summary, special or general court martial? If yes, give date, place, law enforcing authority or type of court of court martial, charge and action taken for each incident, using separate sheet to record this information.
☐ Yes ☐ No
Information to the applicant: As part of our procedure for processing your employment application, your personal and employment references and criminal history may be checked. If you have misrepresented or omitted any facts on this application, and are subsequently hired, you may be discharged from your job. You may make a written request for information derived from the checking of your references and criminal history. I authorize investigation of all statements maintained in this application as may be necessary to arrive at an employment decision. I release from liability any person giving or receiving such information. I understand that this application is not intended to be a contract for employment.
If necessary for employment, you may be required to provide proof of authorization to work in the U.S., have a physical examination and/or a drug test, sign a conflict of interest agreement, and/or a confidentiality agreement and abide by its terms.
RurAL CAP is an “At Will Employer” and employment is terminable at will, either by the employee or by Rural Cap.
I understand and agree to the information shown above.
______Click or tap here to enter text.
Applicant’s Signature Date
Click or tap here to enter text.
Applicant’s Printed Full Name
RurAL CAP is an Equal Opportunity Employer and abides by the federal, state and local laws and regulations. These regulations prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, or national origin. As an Equal Opportunity Employer, we are subject to certain federal recordkeeping/reporting requirements. In order to comply, we will request information from you regarding ethnicity, race, veteran status, and disability status. Agreeing or refusing to provide this information is completely voluntary, will not adversely impact your possible employment, and will only be considered as part of your application upon your request in compliance with our Affirmative Action Plan.
RurAL CAP Alaska Community, Inc.’s
Pre-Hire Voluntary Self-Identification Gender/Race
(Confidential – For Statistical Purposes Only)
Rural Cap Alaska Community, Inc.’s (RurAL CAP) is an equal opportunity employer and does not discriminate based on any classification protected by federal, state or local laws. The Equal Employment Opportunity Commission (EEOC) requires organizations with 100 or more employees to complete an EEO-1 report each year. This form will be used for EEO-1 reporting purposes only and will be kept separate from all other personnel records, and only accessed by the Human Resources Department.
In order to comply, we request that applicants self-identify race/ethnicity. Completion of this form is required, however, submission of the information requested is voluntary, and either refusal or agreement to provide it will not affect your opportunity for employment, or terms or conditions of employment. If you elect not to provide this information, a determination will be made based on EEOC guidelines, whenever possible.
Last Name: Click or tap here to enter text. First Name: Click or tap here to enter text. Middle Name: Click or tap here to enter text.
Job Title Applying For: Click or tap here to enter text. Date: Click or tap here to enter text.
GENDER: ☐ Male ☐ Female ☐ I do not wish to self-identify
RACE/ETHNICITY:
(Please check only one of the descriptions below corresponding to the ethnic group with which you identify.)
☐ / Hispanic or Latino – A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish Culture or origin regardless of race.☐ / White - (Not Hispanic or Latino) A person having origins in any of the original peoples of Europe, the Middle East or North Africa.
☐ / Black or African American - (Not Hispanic or Latino) A person having origins in any of the black racial groups of Africa.
☐ / Native Hawaiian or Other Pacific Islander - (Not Hispanic or Latino) A person having origins in any of the peoples of Hawaii, Guam, Samoa or other Pacific Islands.
☐ / Asian - (Not Hispanic or Latino) A person having origins in any of the original peoples of the Far East, Southeast Asia or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam.
☐ / American Indian or Alaskan Native - (Not Hispanic or Latino) A person having origins in any of the original peoples of North and South America (including Central America) and who maintain tribal affiliation or community attachment.
☐ / Two or More Races - (Not Hispanic or Latino) All persons who identify with more than one of the above five races.
☐ / I do not wish to self-identify.
Rural Cap Alaska Community, Inc.’s
Pre-Hire Voluntary Self-Identification Veteran Status
(Confidential – For Statistical Purposes Only)
Rural Cap is a Federal Contractor and an Equal Opportunity Employer, and abides by the requirements of 41 CFR 60-1.4(a), 60-250, 60-300, 60-300.5(a) and 60-741.5(a). These regulations prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, gender identity, sexual orientation, or national origin. Moreover, these regulations require that covered prime contractors and subcontractors take affirmative action to employ and advance in employment qualified individuals without regard to race, color, religion, sex, national origin, protected veteran status or disability. We are also subject to the Vietnam Era Veterans' Readjustment Assistance Act of 1974, as amended by the Jobs for Veterans Act of 2002, 38 U.S.C. 4212 (VEVRAA), which requires Government contractors to take affirmative action to employ and advance in employment: (1) disabled veterans; (2) recently separated veterans; (3) active duty wartime or campaign badge veterans; and (4) Armed Forces service medal veterans. In order to comply with reporting requirements, we submit annually to the U.S. Dept. of Labor, we request that employees self-identify veteran and disability status. Completion of this form is required, however providing the information requested is voluntary. Refusal or agreement to provide such information will in no way result in adverse treatment. Disclosure will further enable the company to assist you in an appropriate manner concerning your employment.