Piedmont Community Actions, Inc
300-A S. Daniel Morgan Ave. • P.O. Box 5374 Spartanburg, SC 29304 Telephone: (864) 585-8183 Fax: (864) 585-5152

APPLICATION FOR EMPLOYMENT
PCA is an Equal Opportunity Employer

Personal Information
Name: Social Security Number: Home Address: City: Home Phone: State: Zip: Date:

Business Phone:

Can you prove your U. S. Citizenship? Circle One. If not a U. S. Citizen, give Visa No. and Expiration Date:

YES

NO

Have you ever been convicted of a crime within the last five years? YES NO If yes please explain:

Position(s) you are applying for
Title: Referred By: Salary Requirement: Date You Can Start:

Education Record
High School (Name, City, State): Year of Graduation: Business or Technical School (Name, City, State): Dates Attended: Degree Earned:

Undergraduate College (Name, City, State): Dates Attended: Graduate School (Name, City, State): Dates Attended: Revised 9/22/09 -page 1Degree Earned: (please turn to next page) Degree Earned:

Work History (give information about your LAST 3 jobs, starting with the most recent) *** MUST LIST ATLEAST 3
1) Employer: Address: City: Phone: Title/Duties: State: Zip: Dates Employed:

Supervisor’s Name & Title: Reason for Leaving:

2) Employer: Address: City: Phone: Title/Duties: State:

Dates Employed:

Zip:

Supervisor’s Name & Title: Reason for Leaving: 3) Employer: Address: City: Phone: Title/Duties: State: Zip: Dates Employed:

Supervisor’s Name & Title: Reason for Leaving:

Revised 9/22/09 -page 2-

(please turn to next page)

Business References (if applying for your first job, you may use academic references) *** MUST HAVE ATLEAST 3 REFERENCES (NON-FAMILY)
1) Name: Work Phone: Address: City: Relationship to you: State: Zip:

2) Name: Work Phone: Address: City: Relationship to you: State: Zip:

3) Name: Work Phone: Address: City: