PO Box 1067 • 424 South 2nd Ave.
Okanogan WA 98840

voice 509.422.4041 • fax 509.826.7339

Toll free 877 .641.0101 • TDD 800.833.6388

APPLICATION FOR EMPLOYMENT

Date of Application _____/______/______

Name
Last First Middle

Address Social Security #_______-______-______
Mailing

Telephone (____) _______________
City State Zip

Have you applied to this agency before? Yes  No  If yes, approximate date: Mo ______ Year ______

How were you referred to us?

Are you legally eligible for employment in this country? Yes  No 
(Proof of identity and legal authority to work in the U.S. is a condition of employment).

Can you travel if a job requires it? Yes  No 

Do you have a valid Washington State Driver’s License? Yes  No 

Have you been convicted of a felony within the last 7 years? Yes  No  (A conviction will not necessarily

disqualify applicant from employment). If yes, please explain _____________________________________________

__________________________________________________________________________________________

Type of Employment Desired? Full-time  Part-time  Temporary 

Salary Expected $ Date Available for Work ______/______/______

POSITION DESIRED _______________________________________________________________________

SPECIALIZED TRAINING OR SKILLS _____________________________________________________
Computer Experience, Office Machines, __________________________________________________________

Typing/WPM, etc. __________________________________________________________

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SCHOOLS NAME & ADDRESS OF DATES MAJOR GRADUATION

SCHOOL OR COLLEGE From To STUDIES Degree Date

High

School

1

College,
Trade, or
Business 2
Schools

3

Veteran of the U.S. Military Service? Yes  No  If yes, Branch & Rank

Type of Duty

What specialized training did you receive?

Activities: List school, civic, volunteer or business activities and office held (you may exclude those which indicate

race, color, religion, sex, disability, age or national origin).

Please list any languages with which you are familiar, and check all boxes which best describes your skill level.

LANGUAGE Read Write Speak

1

2

3

REFERENCES Please list three previous supervisor’s whom we can contact as a reference. By placing these

references here, you give OCCAC permission to call these people for a reference check.

Name City & Phone Occupation Years

Known

1

2

3

Give names of any relatives and/or acquaintances in the employ of this agency:

Name Occupation Relationship

1

2

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EMPLOYMENT EXPERIENCE Give past employment record as completely as possible starting with your most
recent employer. For any unemployed or self-employed periods, show dates and locations. A detailed resume may be

submitted in addition to the information contained on this page. Former employers may be contacted.

Employer Phone Dates of Employment

( ) From To

Address Work Performed

Job Title

Supervisor

Reason for Leaving

Employer Phone Dates of Employment

( ) From To

Address Work Performed

Job Title

Supervisor

Reason for Leaving

Employer Phone Dates of Employment

( ) From To

Address Work Performed

Job Title

Supervisor

Reason for Leaving

Employer Phone Dates of Employment

( ) From To

Address Work Performed

Job Title

Supervisor

Reason for Leaving

- Attach additional page(s) if necessary -

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ACKNOWLEDGEMENT

OCCAC employees are required to maintain an acceptable driving record, have a valid Washington State Driver’s License

and valid Washington Insurance coverage.

I understand that as a condition of my employment with OCCAC, I will be required to submit an acceptable driving

abstract provided by myself as a condition of my employment.

I, ________________________________, hereby give my permission to:

• have a Criminal Background check performed by OCCAC as a condition for employment.

• ask any and all schools and employers I have indicated in this employment application, in any manner they

choose, for information, whether good or bad. I therefore release all parties or persons connected with any

request for information from claims, liability and damages for whatever reasons arising out of furnishing this

information.

I hereby certify that the facts set forth in this application for employment are true, correct and complete to the best

of my knowledge. I understand that if I am employed, falsified statements or omission of fact on this application

shall be considered sufficient cause for dismissal. I understand that my employment is contingent upon proof of

identity, verification of eligibility for employment in the United States in accordance with the Immigration Reform

and Control Act of 1986, an acceptable Motor Vehicle Record check, and an acceptable Criminal Background

check. I understand that my employment is contingent upon the checking of references furnished by me.

I understand that this application does not create a contract for employment. I understand and agree that, if

hired, my employment is for no definite period of time. I understand, also, that I am required to abide by all rules

and regulations of Okanogan County Community Action Council.

I understand and agree with the statements made pertaining to this application. I agree that a photocopy or

telephonic facsimile of this authorization shall be valid as the original.

Applicant Signature
Date

• 4 –

AFFIRMATIVE ACTION SURVEY

Government agencies require periodic reports on the sex, ethnicity, disability and veteran status of applicants.

This data is for analysis and affirmative action only. Submission of information is voluntary.

Please check one:  Male  Female

Check all that apply:

Race/Ethnic Group  White/Caucasian  Black or African-American 

Hispanic or Latino  American Indian or Alaskan Native 

Asian  Native Hawaiian or Pacific Islander 

Other ___________________________

Check if any of the following are applicable:


Vietnam Era Veteran  Disabled Veteran  Disabled Individual

OCCAC Application for Employment 02-25-2022

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PO Box 1067 • 424 South 2nd Ave.
Okanogan WA 98840

voice 509.422.4041 • fax 509.826.7339

Toll free 877 .641.0101 • TDD 800.833.6388

REFERENCE AUTHORIZATION

To Whom It May Concern:

I, ______________________________, authorize Okanogan County Community Action

Council (OCCAC) to contact all of my former or present employers for the purposes of

verification and reference.

I knowingly and voluntarily release Okanogan County Community Action Council, its individual

employees, and all my former or present employers and their individual employees, from any

and all known and unknown claims for damages or other relief arising out of the agency’s

request for an receipt of employment information, unless my current or former employer is

prohibited by state or federal law from disclosing the information that the agency requests.

__________________________________________________________

Printed name of Applicant

__________________________________________________________

Applicant’s Signature Date

NOTE: A photocopy of this information shall be as valid as the original

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