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Employment Application

Application for Employment

Application for Employment

Your Personal Information

First
Middle
Last
Address
Address
Street Address
Address Line 2
City
State / Province
ZIP / Postal Code
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Are you over the age of 18 years?
Do you have any relatives presently employed with CHANGE, Inc.?
Have you ever worked for CHANGE, Inc. before?
Have you been convicted of a misdemeanor?
Have you been convicted of a felony?

Position You're Applying For

Are you currently employed?
If "Yes", may we contact your employer?
Referral Source:

Education

High School

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College

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Graduate

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Professional

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Bus/Trade

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Employment History (Begin with most recent.)

Most Recent

Please list your previous employers, the dates you worked and the position you held.
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Please provide the name of your supervisor, duties, final salary, and your reason for leaving.

Previous Employer

Please list your previous employers, the dates you worked and the position you held.
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Please provide the name of your supervisor, duties, final salary, and your reason for leaving.

Previous Employer

Please list your previous employers, the dates you worked and the position you held.
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Please provide the name of your supervisor, duties, final salary, and your reason for leaving.

Previous Employer

Please list your previous employers, the dates you worked and the position you held.
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Please provide the name of your supervisor, duties, final salary, and your reason for leaving.

References

Please list two professional references:

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References

Please list two personal references that are not related to you.

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More About You

Maximum file size: 25MB

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Terms and Conditions
PLEASE READ CAREFULLY BEFORE SIGNING • CHANGE, Inc. is an Equal Opportunity Employer. We do not discriminate on the basis of race, religion, color, sex, national origin, ancestry, age or disability. • It is my understanding that this employment application, or the granting of an oral interview, does not represent a contract of employment or a promise of future benefits by CHANGE, Inc. I understand and agree that if hired, my employment will be at-will in nature and may be terminated, with or without cause, at any time, by either myself or CHANGE, Inc. I also understand that this written statement supersedes any and all oral representations made my agents or representatives of CHANGE, Inc. • I understand that I may be subject to a drug/alcohol testing and/or a background check according to CHANGE, Inc.’s policies and passing the drug/alcohol test and background check is a condition of employment. Refusal to submit to testing and/or background check or a positive result shall be sufficient cause for denial of employment or discharge. • I authorize and give CHANGE, Inc. consent to conduct reference checks. • I certify that the information in this application is true, complete, and correct. I understand that false answers, statements, or significant omissions made by me on this application shall be sufficient cause for denial of employment or discharge.
The Programs of CHANGE, Inc. are made possible through funding from Federal, State and Local grants, foundations, and private donations, including the following:
 
Community Services Block Grant Department of Energy Department of Health and Human Resources Department of Health and Human Services Department of Housing and Urban Development Department of Justice Department of Veterans Affairs Northern Panhandle Home Consortium Various Private Foundations Various Private Sources WV Bureau for Children & Families WV Community Advancement & Development WV Development Office WV Supreme Court of Appeals
Family Medical Care is a Health Center Program grantee under 42 U.S.C. 254b, and a deemed Public Health Service employee under 42 U.S.C. 233(g)-(n). This health center receives HRSA and HHS funding and has Federal Public Health Service (PHS) deemed status with respect to certain health or health-related claims, including medical malpractice claims, for itself and its covered individuals.
This material is developed by CHANGE, Inc. and does not infer endorsements by HRSA, HHS, or the U.S. Government.
CHANGE, Inc. is supported by grants from the above mentioned Offices/Programs within the State and US Government. Neither the offices listed nor any of its components operate, control, are responsible for, or necessarily endorse this publication (including, without limitation, its content, technical infrastructure, and policies, and any services or tools provided). The opinions, findings, conclusions, and recommendations expressed are those of the author(s) and do not necessarily reflect the views of the Office/Program.

CHANGE, Inc. builds partnerships, consolidates resources, and integrates services to empower families to overcome the causes of poverty and live healthy lives.

  • 3158 WEST STREET, WEIRTON, WV 26062
  • contact@changeinc.org
  • 304-797-7733

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