LICI Job Application Form – Liberians In Columbus, Inc.

Employment Application

Option to upload resume

Which position are you applying for? *

Market Manager
Mid-Ohio Market Staff Specialist

What is your full name? *

First

Last

How can we get ahold of you?

Telephone Number *

Phone type

Home
Cell
Text

What is you preferred method of communication? *

Email
Text

Email address *

What is your current mailing address?

Employment History

Please list you previous 3 (three) employers starting with your current, or most recent employer

Employer 1

Company Name

Employer 2

Company Name

Employer 3

Company Name

Education

Please outline the highest education you have obtained

Education 1

School / Institution Name

Institution Location

City

State

Country

Did you graduate?

Yes
No

More Information

Education 2

Institution Name

Institution Location

City

State

Country

Did you graduate?

Yes
No

More Information

Education 3

Institution Name

Institution Location

City

State

Country

Did you graduate?

Yes
No

More Information

References

List 3 (three) references that are not relatives

Reference 1

Name

Relationship

Company/Organization

Occupation/Job

Phone number

Email address

Reference 2

Name

Relationship

Company/Organization

Occupation/Job

Phone number

Email address

Reference 3

Name

Relationship

Company/Organization

Occupation/Job

Phone number

Email address

Additional Questions

Date available to start work

MM/DD/YYYY

Desired Salary

Are you available to work overtime if required?

Yes
No

Are you legally eligible for employment in the US?

Yes
No

Proof of citizenship or immigration status will be required upon employment

Are you able to perform the essential functions of the job for which you are applying with or without reasonable accommodation?

Yes
No

Military Status

Are you a Veteran of the United States military services?

Yes
No

If yes, what branch?

Criminal Background

Have you ever been convicted of a felony?

Yes
No

If Yes, please explain:

Please note: A conviction record will not necessarily be a bar to employment and other factors such as time/seriousness of offense, age, and rehabilitation will also be considered

How did you hear about this position?

Please describe

Voluntary Information

The following information is necessary for LICI, to evaluate its hiring practices, to track its progress and effectiveness in complying with equal employment policies and may used in applications for grants. The information is voluntary and will be kept confidential insofar as possible. Information provided will not be negatively considered in any part of the selection process.

Sex/Gender

Male
Female
I choose not to provide my gender

Ethnic Background

Hispanic or Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.
American Indian or Alaska 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 maintain tribal affiliation or community attachment.
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.
White (Not Hispanic or Latino) - A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) - A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
Two or More Races (Not Hispanic or Latino) - All persons who identify with more than one of the above five races.
I choose not to provide race information.

OR CHOOSE TO IDENTIFY A RACE AS LISTED BELOW

Statement of Applicant

I certify that the information in this application is true, complete and correct. I understand that false answers, statements, or significant omissions made by me on this form shall be sufficient cause to 1) cancel further consideration of employment or 2) immediately discharge me from the employer’s service, whenever it is discovered. I understand and agree that, if hired; my employment will be at-will in nature and may be terminated, with or without cause, at any time, by either myself or my employer. I give Liberians in Columbus, Inc., the right to investigate all references and to secure additional information me, if job related. I hereby release from liability the employer and its representatives for seeking such information and all other persons, corporations or organizations for furnishing such requests. I understand that passing the background check (including drug screen) is a condition of employment and negative results can be grounds for dismissal, even if an offer has been made to me and I have been hired.

Applicant acknowledgment *

I have read and agree to the Statement of Applicant.

Applicant full name *

Date *

MM/DD/YYYY