Coosa Valley Youth Services

Online Application

We consider applicants for all positions without regard to race, religion, creed, gender,national origin, age, disability, marital or veteran status, or any other legally protected status.

Application Date:
Position(s) Applied For:
Full Name:
Address (Number,Street,etc.):
City,State,Zip:
Telephone Number(s):
Email Address:

Best time to contact you at home: AM PM Who referred you?

Are you above the minimum working age of 21? Yes No

Have you ever been employed by us before? Yes No If Yes, give date

Are any of your friends or relatives employed by us? Yes No

Are you currently employed? Yes No

May we contact your present employer? Yes No

Are you legally permitted to work in this country? Yes No
Proof of citizenship or immigration status will be required

Have you ever been charged with or convicted of a felony, including felony DUI, or as an accessory
to a felony, at any time, in any state? Yes No
If yes, please give date of charge or conviction and explain:

Charge or conviction will not necessarily disqualify an applicant from employment

Date available to work: What is your desired salary range?

Are you available to work Full-Time?   Yes No
Are you available to work Part-Time? Yes No
Are you available to work 1st Shift?    Yes No
Are you available to work 2nd Shift?   Yes No
Are you available to work 3rd Shift?   Yes No

List previous employers, beginning with current or most recent

Employer:  Dates Employed:
Address:  Telephone:
Job Title:  Supervisor:
Duties:
Starting Wage:  Ending Wage:   Full-Time Part-Time Temp
Reason for Leaving:  May we Contact? Yes No
__________________________________________________________________________________________

Employer:  Dates Employed:
Address:  Telephone:
Job Title:  Supervisor:
Duties:
Starting Wage:  Ending Wage:   Full-Time Part-Time Temp
Reason for Leaving:  May we Contact? Yes No
__________________________________________________________________________________________

Employer:  Dates Employed:
Address:  Telephone:
Job Title:  Supervisor:
Duties:
Starting Wage:  Ending Wage:   Full-Time Part-Time Temp
Reason for Leaving:  May we Contact? Yes No
__________________________________________________________________________________________

Employer:  Dates Employed:
Address:  Telephone:
Job Title:  Supervisor:
Duties:
Starting Wage:  Ending Wage:   Full-Time Part-Time Temp
Reason for Leaving:  May we Contact? Yes No
__________________________________________________________________________________________

Employer:  Dates Employed:
Address:  Telephone:
Job Title:  Supervisor:
Duties:
Starting Wage:  Ending Wage:   Full-Time Part-Time Temp
Reason for Leaving:  May we Contact? Yes No
__________________________________________________________________________________________

Elementary School (Name & Address):
Years Completed:   Graduated? Yes No

High School (Name & Address):
Years Completed:   Diploma? Yes No

Undergraduate College (Name & Address):
Years Completed:   Major/Minor:  Degree:

Graduate College (Name & Address):
Years Completed:  Course of Study: Degree:

Other Education (Specify):

Describe any specialized training, certifications, apprenticeships, skills, or
extra-curricular activies:

Describe any job-related training received in the United States military:

  List three References

Name: Address: Phone:
Name: Address: Phone:
Name: Address: Phone:

I understand that if offered a position in a "safety-sensitive" job at this agency, I will have to pass a drug screen.
During the interview process, applicants will be required to complete a written application.
To facilitate this process, you are encouraged to print a copy of your completed application prior to submitting.
You may then bring the printed copy of your application, along with your resume, to the interview.