APPLICATION FOR EMPLOYMENT EQUAL ACCESS TO PROGRAMS, SERVICES AND EMPLOYMENT IS AVAILABLE TO ALL PERSONS.  THOSE APPLICANTS REQUIRING REASONABLE ACCOMMODATION TO THE APPLICATION AND OR INTERVIEW PROCESS SHOULD NOTIFY A REPRESENTATIVE TO THE HUMAN RESOURCES DEPT.

POSITION APPLIED FOR:                DATE:- mm/dd/yy

REFERRAL SOURCE:   ADVERTISEMENT  EMPLOYEE  WALK-IN  RELATIVE

Name
Street Address
City	State  Zip
Home Phone	Cell
E-mail

SOCIAL SECURITY NUMBER:                                                *This information will be asked at time of interview.

LICENSE NUMBER(CNA/LPN/RN/CHHA): EXPIRATION DATE:- mm/dd/yy

MAY WE CONTACT YOU AT WORK?:

YES, PHONE NUMBER         NO

HAVE YOU EVER SUBMITTED AN APPLICATION HERE BEFORE?: YES NO

HAVE YOU EVER BEEN EMPLOYED HERE BEFORE?: YES NOmm/dd/yy

ARE YOU LEGALLY ELIGIBLE FOR EMPLOYMENT IN THIS COUNTRY? YES NO

DATE AVAILABLE FOR WORK?:  mm/dd/yy  TYPE OF EMPLOYMENT DESIRED: PRIVATE DUTY STAFFING

ARE YOU ABLE TO PERFORM THE JOB APPLIED FOR WITHOUT ANY RESTRICTIONS?:

YES      NO  IF ANSWERED NO PLEASE EXPLAIN:

HAVE YOU EVER BEEN BONDED?: YES NO

        IF YES, PLEASE PROVIDE DATE(S) AND DETAILS:

HAVE YOU EVER PLED "GUILTY" OR "NO CONTEST" TO, OR BEEN CONVICTED OF A CRIME?: YES NO

        IF YES, PLEASE PROVIDE DATE(S) AND DETAILS:

* Answering Yes to these questions does not constitute an automatic bar to employment.  Factors such as date of the offense, seriousness and nature of the violation, rehabilitation   and position applied for will be taken into account. 

HAVE YOU LIVED IN PENNSYLVANIA FOR THE LAST 2 YEARS?: YES NO

WORK EXPERIENCE

FROM:mm/dd/yy TO:mm/dd/yy 

EMPLOYER:PHONE:

JOB TITLE:ADDRESS:

IMMEDIATE SUPERVISOR AND TITLE:

NATURE OF WORK AND RESPONSIBILITIES:

REASON FOR LEAVING:

HOURLY RATE:

FROM:mm/dd/yy TO:mm/dd/yy 

EMPLOYER:PHONE:

JOB TITLE:ADDRESS:

IMMEDIATE SUPERVISOR AND TITLE:

NATURE OF WORK AND RESPONSIBILITIES:

REASON FOR LEAVING:

HOURLY RATE:

APPLICANT STATEMENT:  I CERTIFY THAT ALL INFORMATION I HAVE PROVIDED IN ORDER TO APPLY FOR AND SECURE WORK WITH THE EMPLOYER IS TRUE, COMPLETE AND CORRECT.  I UNDERSTAND THAT ANY INFORMATION PROVIDED BY ME THAT IS FOUND TO BE FALSE, INCOMPLETE OR MISREPRESENTED IN ANY RESPECT, WILL BE SUFFICIENT CAUSE TO (I) CANCEL FURTHER CONSIDERATION OF THE APPLICATION, OR (II) IMMEDIATELY DISCHARGE ME FROM THE EMPLOYERS SERVICE, WHENEVER IT IS DISCOVERED, EXPRESSLY AUTHORIZE, WITHOUT RESERVATION THE EMPLOYER, IT'S REPRESENTATIVES, EMPLOYEES OR AGENT TO CONTACT AND OBTAIN INFORMATION FOR ALL REFERENCES (PERSONAL AND PROFESSIONS), EMPLOYERS, PUBLIC AGENCIES, LICENSING AUTHORITIES AND EDUCATIONAL INSTITUTIONS AND SEEKING, GATHERING AND USING SUCH INFORMATION IN THE EMPLOYMENT PROCESS AND ALL OTHER PERSONS, CORPORATIONS, OR ORGANIZATIONS FOR FURNISHING SUCH INFORMATION ABOUT ME  I UNDERSTAND THAT THE EMPLOYER DOES NOT UNLAWFULLY DISCRIMINATE IN EMPLOYMENT AND NO QUESTION ON THE APPLICATION IS USED FOR THE PURPOSE OF LIMITING OR EXCUSING ANY APPLICANT FOR CONSIDERATION FOR EMPLOYMENT ON A BASIS PROHIBITED BY APPLICABLE LOCAL, STATE OR FEDERAL LAW.

I UNDERSTAND THAT THIS APPLICATION REMAINS CURRENT FOR ONLY 30 DAYS.  AT THE CONCLUSION OF THAT TIME, IF I HAVE NOT HEARD FROM THE EMPLOYER AND STILL WISH TO BE CONSIDERED FOR EMPLOYMENT, IT WILL BE NECESSARY TO REAPPLY AND FILL OUT A NEW APPLICATION.  IF I AM HIRED, I UNDERSTAND THAT I AM CONSIDERED AN EMPLOYEE AT WILL.

NAME OF APPLICANT:(Please type name, signature will be required at time of interview)