Personal Information

Name:       Today's Date:
SSN:                        Email Address:
Address:      Apt: #:
City:           State:           Zip:
Home phone:           Business phone:
Can you prove your U.S. citizenship? Yes      No
If not a U.S. citizen:  Visa #:   Expiration Date:

Position(s) for Which You Are Applying

Title:      Salary Requirement:
Referred By:      Start Date:

Education Record

High School:      City:      State:
Year of Graduation:

Business or Technical School: City: State:
Dates Attended:      Degree(s) Earned:

Undergraduate College:      City:      State:
Dates Attended:      Degree(s) Earned:

Graduate School:      City:      State:
Dates Attended:      Degree(s) Earned:

Work History -- give information about your last three (3) jobs
Must give at least three (3) -- Start with your most recent job

1. Employer:    Dates Employed: From: To:
Address:    City:    State:    Zip:
Phone:           Ending Salary:
Title:           Duties:
Supervisor's Name & Title:
Reason For Leaving:

2. Employer:    Dates Employed: From: To:
Address:    City:    State:    Zip:
Phone:           Ending Salary:
Title:           Duties:
Supervisor's Name & Title:
Reason For Leaving:

3. Employer:    Dates Employed: From: To:
Address:    City:    State:    Zip:
Phone:           Ending Salary:
Title:           Duties:
Supervisor's Name & Title:
Reason For Leaving:

Business References (if applying for your first job, you may use academic references)
You must have at least three non-family references

1. Name:      Work Phone:
Address:    City:    State:    Zip:
Relation to You:

2. Name:      Work Phone:
Address:    City:    State:    Zip:
Relation to You:

3. Name:      Work Phone:
Address:    City:    State:    Zip:
Relation to You:

Please Read and then Submit

By clicking on the Submit Button, I am stating that the information that I have provided to Piedmont Community Actions in this Employment Application is true and correct.

If I am employed by PCA and any misstatement or omission is found, I understand that this will be grounds for immediate termination. I understand that employment with PCA is employment at will. I give PCA permission to check my job history and personal references as listed on this application or my resume.

A DRUG TEST WILL BE GIVEN TO ALL NEW EMPLOYEES. A POSITIVE TEST RESULT FOR USE OF DRUGS WILL BE GROUNDS FOR IMMEDIATE RELEASE FROM EMPLOYMENT WITH PCA.