Online Employment Application

PERSONAL INFORMATION

Name (Last, First, Middle Initial)

Street Address

City, State, Zip Code

Phone Number	Email Address	Preferred Method of Contact

Shift Prefernce:	Are you eligible to work in the United States?
Days Evenings Overnights Any	(If offered employment, you will be required to provide documentation to verify eligibility.)

Were you referred by CCSI by a employee?	If yes, what is their name?	Are you 18 years of age or older?

REFERENCES Please list three professional references. By listings these references, CCSI assumes we may contact these people. Do not list relatives.

Name	Relationship	Phone

EMPLOYMENT HISTORY List your four most recent positions relevant to the position you are applying for.

Dates Employed (month/year)		Position Title
From:	To:
Wages
Start:	Final:

Organization Name/Address	May we contact your references

	Supervisor's Name/Phone

Reason for leaving:	Please explain your reason for leaving

Duties:

Dates Employed (month/year)		Position Title
From:	To:
Wages
Start:	Final:

Organization Name/Address	May we contact your references

	Supervisor's Name/Phone

Reason for leaving:	Please explain your reason for leaving

Duties:

Dates Employed (month/year)		Position Title
From:	To:
Wages
Start:	Final:

Organization Name/Address	May we contact your references

	Supervisor's Name/Phone

Reason for leaving:	Please explain your reason for leaving

Duties:

Please read carefully:

CCIS is subject to certain governmental recordkeeping and reporting requirements for theadministration of civil rights laws and regulations. In order to comply with these laws, CCSI invites employees to VOLUNTARILY self-identify their race or ethnicity. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information will be kept confidential and may only be used in accordance with the provisions or applicable laws, executive orders, and regulations, including those that require the information to be summarized and reported to the federal government for civil rights enforcement. When reported, data will not identify any specific individual.

RACE/ETHNICITY Select one or more

	Prefer not to answer.
	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.
	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.
	Native Hawaiian or other Pacific Islander, not Hispanic or Latino: A person having origins in any of the original peoples of Hawaii, Guam, Samoa or other Pacific Islands.
	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 maintains tribal affiliation or other community attachment.
	Two or more races, not Hispanic or Latino: Any person who identifies as being America Indian or Alaska Native, Asian, Black or African American, Hispanic or Latino, Native Hawaiian or other Pacific Islander, or in any combination of these identifiers, or someone who identifies as White and as any of the other identifiers.
	Disabled Individual: Federal Regulations define a disabled individual as one who 1) has a physical or mental impairment which substantially limits one or more of such individual’s major life activities; 2) has a history of such impairment; or 3) is regarded as having such an impairment.

Special notice to Vietnam Era Veterans, Disabled Veterans and Individuals with physical or mental disabilities: CCSI is subject to the Vietnam Era Veterans Readjustment Act of 1974 and the Rehabilitation Act of 1973 and are required to take affirmative action to employ and advance in employment qualified disabled veterans, veterans of the Vietnam era and qualified handicapped individuals. You are invited to volunteer this information, if you qualify, to assist in proper placement and determining reasonable accommodation. This information will be considered confidential. Refusal to provide this information will not adversely affect your consideration for employment. If you wish to be identified, please check if any of the following are applicable:

Vietnam Era Veteran: Federal Regulations define a veteran of the Vietnam Era as one who: 1) served on active duty for a period of more than 180 days, any part of which occurred between August 5, 1964, and May 7, 1975, and was discharged or released with other than a dishonorable discharge; or 2) was discharge or released from active duty for a service connected disability if any part of such active duty was performed between August 5, 1964 and May 7, 1975.

Special Disabled Veteran (30% or more disability): Federal Regulations define a special disabled veteran as one who: 1) is entitled to compensation under laws administered by the Veterans’ Administration for a disability rated 30% or more; or 2) was discharged or released from active duty because of a service-connected disability.

This form is not used for employment decisions. If you have a disability and need an accommodation so that you can perform the duties of the job for which you are applying, please notify us in some other manner.

Please state any additional information you feel may be helpful to us in considering your application, i.e., volunteer experience, previous training not listed elsewhere, etc.

Disclaimer & Signature – I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.
Digital Signature:			Spam Check: