APPLICATION FOR EMPLOYMENT
Name
Street or P.O. Box
It Is our policy to comply with all applicable state and federal laws prohibiting discrimination in employment.
Date
City
State
Home Phone Number
Alternate Phone Number
How did you learn of this opening?
Are you authorized to work in the U.S. on an unrestricted basis?  
High School
Have you worked here before? 
Are you over 18 years of age?
Have you read the job description? You must read it.  If you have not read the job description click here, read it, and then continue with this form.  Have you read the essential job functions and job description listed on the Job Openings page?  
Can you perform these essential functions with our without reasonable accommodations? 
Are there any hours or days you cannot or will not work?
Position Preferred
Are you willing to work overtime? 
Have you ever been convicted of a felony? 
(A conviction will not necessarily disqualify an applicant for employment.) 
 If yes, describe conditions 
EDUCATION
NAME & LOCATION OF SCHOOL
YEAR GRADUATED
MAJOR
DIPLOMA/DEGREE
Work History
POSITION APPLIED FOR 
Telephone
Most Recent Employer
College/Univ.
College/Univ.
Other Training  or Education
VERY IMPORTANT **** Please do not copy and paste text. Type text onlyIn addition to your work history, specifically what other experience, skills, or qualifications do you have for the job for which you applied?
1. 
2. 
Wage or salary desired 

When can you start?
May we contact your present employer? 
Address
Start Date
Starting Salary: $
Per
Starting Position
End Date
Ending Salary: $
Per
Ending Position
Name and Title of Supervisor
Description of Duties
Reason for Leaving
Space is limited. Do not exceed text box.
Previous Employer
Address
Telephone
Start Date
Starting Salary: $
Per
Starting Position
End Date
Ending Salary: $
Per
Ending Position
Name and Title of Supervisor
Description of Duties
Reason for Leaving
Space is limited. Do not exceed text box.
Previous Employer
Address
Telephone
Start Date
Starting Salary: $
Per
Starting Position
End Date
Ending Salary: $
Per
Ending Position
Name and Title of Supervisor
Description of Duties
Reason for Leaving
Space is limited. Do not exceed text box
Do you certify and agree with the above agreement?
Applicant's Name
Date
PERSONAL REFERENCES
1.    Name
Address
Telephone Number
Business or Occupation
2.    Name
Address
Telephone Number
Business or Occupation
3.    Name
Address
Telephone Number
Business or Occupation
4.    Name
Address
Telephone Number
Business or Occupation
I HEREBY CERTIFY THAT THIS APPLICATION CONTAINS NO WILLFUL MISREPRESENTATION OR
FALSIFICATION AND THAT THE INFORMATION GlVEN BY ME IS TRUE AND COMPLETE TO THE BEST OF MY
KNOWLEDGE AND BELIEF. YOU MAYCONTACT PREVIOUS EMPLOYERS AND REFERENCES TO VERIFY THE
INFORMATION.
Do you certify and agree with the above agreement?
Applicant's Name
Date
Upon completion of this LDCAA Employment Application please left click the Submit button above.  Upon clicking this button all information will be sent to the LDCAA Personnel Department for processing and this screen will be cleared. 
Zip
Are you 21 years of age or older?
Are you 25 years of age or older?
Answer the following question only if you are applying for a position with Head Start.
Answer the following question only if you are applying for a position with Transit.
Address
E-Mail
Optional information used for governmental record requirements.  The following information 
will not be submitted on your application but will be kept for record requirements.
Please click on your choice below.
Gender
Race/Ethnicity
LDCAA will only accept applications for current job openings
LDCAA will only accept applications for current job openings 
Instructions
1.  Submit your application by clicking the "Left Click To Submit Application" button below.

2.  If you would like to send a resume, in addition to your applicationyou may send a resume by E-mail to       cleforce@littledixie.org    .  Applications are mandatory.  Resumes are optional.  
LDCAA will only accept applications and resumes for current job openings 
Your application will only be considered for the current job opening(s) for which you applied. Your application will not be considered for any other future job openings. If you wish to apply for a job opening in the future you must complete a new application for that job. 

LDCAA uses E-Verify.  Click here for "This Organization Participates in E-Verify" Poster.
U.S. law requires companies to employ only individuals who may legally work in the United States – both U.S. citizens and foreign visitors who are permitted to work. E-Verify is an Internet-based system that allows businesses to determine the eligibility of their employees to work in the United States.

The agency offers no employment contracts nor does it guarantee any minimum length of employment. The agency reserves the right to terminate any employee at any time "at-will," with or without cause, and for any reason not prohibited by statute. A supervisor or program director of the agency has no authority whatsoever to make any contrary representations to any employee.

A background check may be required.

This institution is an equal opportunity provider and employer.
If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at http://www.ascr.usda.gov/complaint filing cust.html, or at any USDA office, or call (866) 632-9992 to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter to us by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at program.intake@usda.gov.

PAY TRANSPARENCY NONDISCRIMINATION PROVISION
The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor’s legal duty to furnish information. 41 CFR 60-1.35(c)
APPLICANT'S CERTIFICATION AND AGREEMENT: I certify that the facts set forth in this Application for Employment are true and complete to the best of my knowledge.  I understand that If I am employed, false statements, omissions or misrepresentations may result in my dismissal.  I authorize the Company to make an investigation of any of the facts set forth in this application. I understand that employment at this Company is "at-will", which means that either I or the Company can terminate the employment relationship at any time, and with or without prior notice, and for any reason not prohibited by statute.  All employment is continued on that basis.  I understand that no supervisor, manager or executive of the Company, other than the president has any authority to alter the foregoing.
Accessibility
Are you related in any way to an LDCAA employee, Board Member, or Board Member Spouse? 
If yes, type their name(s) to the right.  (Click here for a complete list of Employees, Board Member Names and Spouses.) 
You must choose one job listing per box. Click on down arrow and left click on your choice.
Veteran's Voluntary Self-Identification Information
Little Dixie Community Action Agency, Inc. is an Equal Opportunity Employer.  As required by law, we must record certain information to be made a part of our Affirmative Action Program. Employees are asked to participate in the Affirmative Action Program by reporting their veteran status as described below. In requesting this information you are also advised that: (a) employees (or applicants) are under no obligation to respond, but may do so in the future if they choose; (b) responses will remain confidential within the Human Resources Department; and (c) responses will be used only for the necessary information as required   by law and to include in our Affirmative Action Program. Refusal to provide this information will not subject employees (or applicant) to any adverse treatment or employment.
Please see Definitions Below
• Disabled veterans.
---(1) A veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs, or  
---(2) A person who was discharged or released from active duty because of a service-connected disability. 
• Recently separated veterans (3 years).
---Recently separated veteran means any veteran during the three-year period beginning on the date of such veteran's discharge or release from active duty in the U.S. military, ground, naval or air service. 
• Recipients of armed forces service medal. 
---Armed Forces service medal veteran means any veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985 ( 61 FR 1209 ).  
• Veterans who served in active duty in a war or campaign for which a campaign badge was authorized.
---A veteran who served on active duty in the U.S. military, ground, naval or air service during a war or in a campaign or expedition for which a campaign badge has been authorized, under the laws administered by the Department of Defense. 

You may check any applicable status from the following choices.
Voluntary Self-Identification of Disability
Voluntary Self·Identification of Disability​Form CC-305
OMB Control Number 1250-0005
Expires 1/31/2017
Page 1 of 2

Why are you being asked to complete this form?

Because we do business with the government, we must reach out to, hire. and provide equal opportunity to
qualified people with disabilities. To help us measure how well we are doing, we are asking you to tell us If
you have a disability or if you ever had a disability. Completing this form is voluntary. but we hope that you will
choose to fill it out. If you are applying for a job. any answer you give will be kept private and will not be used
against you in any way.

If you already work for us, your answer will not be used against you in any way. Because a person may
become disabled at any time. we are required to ask all of our employees to update their information every five
years. You may voluntarily self-Identify as having a disability on this form without fear of any punishment
because you did not identity as having a disability earlier.

How do I know if I have a disability?

You are considered to have a disability If you have a physical or mental impairment or medical condition that
substantially limits a major life activity, or if you have a history or record of such an Impairment or medical
condition.

Disabilities include, but are not limited to:

• Blindness      • Autism                   • Bipolar disorder                  • Post-traumatic stress disorder (PTSD)
• Deafness      • Cerebral palsy      • Major depression                • Obsessive compulsive disorder
• Cancer          • HIV/AIDS               • Multiple sclerosis (MS)       • Impairments requiring the use of a wheelchair
• Diabetes       • Schizophrenia       • Missing limbs or                  • Intellectual disability (previously called mental
• Epilepsy        • Muscular                • partially missing limbs           retardation)
                            dystrophy

Please check one of the boxes below:
Voluntary Self-Identification of Disability
Voluntary Self·ldentlflcatlon of Disability ​Form CC-305
OMB Control Number 1250-0005
Expires 1/31/2017
Page 2 of 2
Reasonable Accommodation Notice

Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities.
Please contact Clark LeForce, Human Resources, 580-326-3351, cleforce@littlediixe.org, 209 N. 4th St., Hugo, Oklahoma 74743 if you require a reasonable accommodation to apply for a job or to perform your job. Examples
of reasonable accommodation lndude making a change to the application process or work procedures,
providing documents in an alternate format. using a sign language Interpreter, or using specialized equipment.


------------------------------------
Section 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal
employment obngations of Federal contractors, visit the U.S. Department of Labor's Otftee of Federal Contract
Compliance Programs (OFCCP) website at www.dol.gov/ofccp.


PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond
to a collection of information unless such collection dlsplays a valid OMB control number. This survey should take about 5
minutes to complete.
Click button to submit application.........                
(****You may see an error message after you click Submit.  Ignore the message.  Your application is still being sent.  We are working on this problem.)
I identify as one or more of the classifications of protected Veterans listed above.
I am Not a Veteran.
I choose not to identify.
YES, I HAVE A DISABILITY (or previously had a disability).
NO, I DON'T HAVE A DISABILITY.
I DON'T WISH TO ANSWER.