Mountain Area Community Services, Inc. will confirm dates of employment, positions held, and reasons for leaving with prior employers. Explain ALL gaps in employment and other information relevant to eligibility, qualification, and suitability with prior employers in the “additional information” section.

Present or Last Employer

Prior Employer

Earlier Employer

1 Personal Reference & 2 Professional References

Please note: The information provided in this section must be current and complete. Our inability to contact the references provided will delay the hiring process.

First Reference
Second Reference
Third Reference

Additional Training

Human Services

Additional Information

By sending this a[pplication form I attest that I have been honest and thorough in completing this document. I understand that if employed, I will have been hired at the will of my employer and that my employment may be terminated at any time, with or without cause and with or without notice.

All information provided is subject to the North Carolina Open Records Law. Mountain Area Community Services, Inc. does not discriminate on the basis of race, color, national origin, sex, religion, age or disability in employment or the provision of services.

I certify that the responses entered by me on this employment application are true and complete. I understand that any misleading or incorrect statements may render this application void. I agree the company is not liable in any respect if any employment is terminated because of false statements, answers, or omission made by me in the application.

I also understand that, if accepted for employment, I shall be required to provide proof of identity and eligibility (Social Security Card or copy of Birth Certificate and current Driver’s License/Picture Identification) to work in the United States as a condition of employment. In connection with this application I authorize all corporations, companies, credit agencies, education institution, licensing agencies person, law enforcement agencies, military services, and former employers to release information that they may have about me to Mountain Area Community Services, Inc. or its agents and release them from any liability form doing so. I understand that criminal/abuse/neglect checks will be performed by Mountain Area Community Services, Inc. concerning information contained on this application and that any offer of employment and continued employment is contingent upon receipt of satisfactory clearance.

I understand that proof of current driver’s license, current and adequate vehicle insurance coverage, valid CPR and First Aid Certification must be provided upon employment. Verification of completion of at least high school education of GED (copy of diploma, signed statement from school official, high school transcripts, teaching certificate, etc.) must also be presented upon employment. *For QP applicants, an official copy of college transcripts is required. For some professional positions (i.e. LP, RN, MD, PHD, etc.) copy of credentials and/or licenses related to services to be provided will be required.

I declare that I am not a pedophile or child molester and that I have not perpetrated physical abuse, sexual abuse, emotional abuse or neglect against a child or adult nor have I ever been convicted of any of these acts.


I also declare that I have not been convicted of drug charges and am not a user of illegal drugs.


I understand that I shall be subject to drug screening upon employment by Mountain Area Community Services, Inc. I also understand that if at any point I am suspected of not complying with the drug and alcohol policies as set forth by Mountain Area Community Services, Inc., I may subject to further screening which may or may not result in disciplinary action or immediate termination.