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Application for Employment
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Are you 18 years or older?
Have you ever been convicted of a crime or are there any charges pending against you currently?
If yes, please describe below:
AOK Site Coordinator
If other, please describe desired position below:
Date you can start:
Please indicate specified days of the week and times you are available to work. Example: Available MWF 9 AM - 4 PM, TR 2 PM - 8 PM.
Are you currently employed?
If so, may we contact your present employer?
Ever applied to this agency before?
If yes, when?
Present membership in National Guard or Reserves?
Location (City & State)
# No Years Attended
Did You Graduate?
Please list High School, College, Graduate School, or any Trade/Business/Correspondence School under Education.
Name of Employer
Reason for Leaving
Please list last three employers, starting with last one first. Click (+) to add a new employer.
Drop files here or
Please include your résumé. A cover letter is optional.
Please list the names and information of three persons not related to you whom you have known for at least one year.
Three References are Required. Click (+) to add a new reference.
Do you have any physical limitations that prelude you from performing any work for which you are being considered?
If yes, what can be done to accommodate your limitation?
In case of emergency, please notify:
Click (+) to add a new contact.
The information provided on this application for employment is true, correct and complete. I understand that if I am employed, any misstatement or omission of fact on this application may result in my discharge regardless of when the agency learns of the misstatement or omission. I understand that the agency will require pre-employment check for child abuse/neglect history, and run a criminal background check. I hereby consent to child abuse history and criminal background check, and authorize the release of the results to the agency. I understand that any offer of employment to me is contingent upon the results of these checks and further that the agency will not employ any applicant who has a history of child abuse/neglect or conviction of related offenses. I understand that if the position for which l am applying requires a license/certification that I am solely responsible for obtaining and maintaining said license. I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an "at will" nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this "at will" employment relationship may not be changed by any written document or by conduct unless an authorized executive of this organization specifically acknowledges such change in writing. I hereby authorize investigation of all statements in this application and request any company, institution, or persons contacted as part of this investigation to provide any and all pertinent information and to assure their cooperation, I hereby release them from all liability for any damage that may result from furnishing same to the agency.
I have read and understood the Applicant's Statemnet
This form has been designed to strictly comply with State and Federal fair employment practice laws prohibiting employment discrimination. Approved: September 2013
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To bring peace to homes, strength to individuals and families, and positive impact to community through prevention and crisis intervention.
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