Career Opportunities Form

* = Required Information

APPLICATION FOR EMPLOYMENT

All prospective employees will receive consideration without discrimination because of race, color, creed, age, natural origin or handicap. All information provided herein will be kept confidential.

Last Name*

First Name*

Middle

Date*

Street Address*

City *

State

Zip Code*

Home/Cell Phone*

Email address*

Social Security Number*

Date of Birth*

Emergency contact (person not living with you)

Have you ever applied for employment with this Agency?

Yes

How many hours a week are you available for work?

Are you legally eligible for employment in the United States?

Yes

How did you learn of our organization?

Newspaper Ad

Agency employee

Other

Are you willing to work

Evenings?

Weekends?

Position applying for

License or Certificate number(s)

EDUCATION

College:

School Name

Location of School

Course of Study

Years of Study

Degree/Diploma

School Name

Location of School

Course of Study

Years of Study

Degree/Diploma

Vo-Tech or Trade:

School Name

Location of School

Course of Study

Years of Study

Degree/Diploma

School Name

Location of School

Course of Study

Years of Study

Degree/Diploma

High School:

School Name

Location of School

Course of Study

Years of Study

Degree/Diploma

School Name

Location of School

Course of Study

Years of Study

Degree/Diploma

Other:

School Name

Location of School

Course of Study

Years of Study

Degree/Diploma

School Name

Location of School

Course of Study

Years of Study

Degree/Diploma

EMPLOYMENT

--List the last five years’ employment history, starting with the most recent employer.

Company 1

Company Name

Telephone

Address

Dates of Employment:

From

City:

State

Zip Code

Starting Pay

Job Title and Describe your work

Reason for leaving

Company 2

Company Name

Telephone

Address

Dates of Employment:

From

City:

State

Zip Code

Starting Pay

Job Title and Describe your work

Reason for leaving

Company 3

Company Name

Telephone

Address

Dates of Employment:

From

City:

State

Zip Code

Starting Pay

Job Title and Describe your work

Reason for leaving

APPLICATION FOR EMPLOYMENT

Was your last name different from your present name during the above listed jobs?

Yes

What was your name?

Are you currently employed?

Yes

Do you have reliable transportation?

Yes

PROFESSIONAL REFERENCES

Persons who can furnish information about job performance

1. Name

Telephone

Fax

Address

2. Name

Telephone

Fax

Address

3. Name

Telephone

Fax

Address

GENERAL

Have you ever been convicted of a crime in the past 5 years, barring employment in a Home Care and community support Agency?

Yes

Conviction will not necessarily disqualify an applicant from employment.

Describe in full

Are you capable of performing the job set forth in the job description?

Yes

Which job requirement can you not meet?

APPLICATION FOR EMPLOYMENT

CREDENTIALS/SPECIALIZED SKILLS & QUALIFICATIONS/EQUIPMENT OPERATED

List all states in which licensed giving registration and expiration date. Summarize special job-related skills and qualification acquired from employment or other experience.

I certify that the facts contained in this application are true and complete to the best of my knowledge and understand, that, if employed, falsified statements on this application SHALL BE GROUNDS FOR DISMISSAL.

I Authorize complete investigation of all statements contained herein and herby give my full permission for the Agency to contact and fully discuss my background and history with all persons and entities listed above to give the Agency any and all information concerning my previous employment and any information they may have, and release all former employees and others listed above from all liability for any damage that my result from furnishing the same to the Agency.

I understand and agree that, if hired, my employment is for no definite period arid may, regardless of the date of payment of my wages and salary, be terminated at any time for any lawful reason, without prior notice and with or without cause.

This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period shall inquire as to whether or not applications are being accepted at that time.

Signature

Clear

Date *

APPLICANT REFERENCE CHECK (1)

To Whom It May Concern:

The applicant named below has submitted an application for employment with our firm. Please verify employment and rate the performance of this candidate. This information will not be given to the employee.

To be filled out by applicant:

Applicant Name

Date of Application

Previous Employer

Contact Person

Address

Phone Number

Fax

I hereby authorize the following information to be released for all previous employers listed. I release you and all persons and organizations from all claims and liabilities of any nature from any information given.

Applicant's Signature

Clear

Date *

To be completed by previous employer:

Date of employment:

From

Position Held

Would you rehire this individual?

Yes

Responsibilities

Reason for Leaving

Rate of Pay

Type of Pay

Weekly

Biweekly

Salary

Additional Comments (training/skills)

Reference check performed by

APPLICANT REFERENCE CHECK (2)

To be filled out by applicant:

Applicant Name

Date of Application

Previous Employer

Contact Person

Address

Phone Number

Fax

Applicant's Signature

Clear

Date *

To be completed by previous employer:

Date of employment:

From

Position Held

Would you rehire this individual?

Yes

Responsibilities

Reason for Leaving

Rate of Pay

Type of Pay

Weekly

Biweekly

Salary

Additional Comments (training/skills)

Reference check performed by

Employee Emergency Contact Information

Employee Name

Current Address

Home Phone

Cell Phone

Next of kin

Phone Number

Relationship

Address

In case of emergency, please contact

Name

Phone Number

Relationship

Address

Please notify this Agency immediately if any of the emergency

HEPATITIS VACCINE REQUIREMENT

I acknowledge that I am at risk of exposure or have been unknowingly exposed to Hepatitis B as a result of my employment and acknowledge that the Agency will arrange for me to receive the Hepatitis vaccine at no cost to myself. It is my decision to:

Request that I receive the Hepatitis vaccine.

Refuse the Hepatitis vaccine and HOLD HARMLESS THE AGENCY. I understand that by declining the vaccine I continue to be at risk of acquiring Hepatitis B, a serious disease. If, in the future, I continue to have occupational exposure to blood or other potentially infectious materials, and I want to be vaccinated with Hepatitis B vaccine, I can receive the vaccine series at no charge to me.

Provide written proof of immunity (attach)

Provide written proof of previous vaccination (attach)

Provide written proof of medical contraindication (attach)

Signature of Applicant

Clear

Date *

TB TARGETED MEDICAL QUESTIONNAIRE FORM

To be completed by employee

1. Have you ever had a positive TB skin test or history of TB infection?

Yes

Signature of Applicant

Clear

Date *

Reviewed by Signature

Clear

Date *

PRE-EMPLOYMENT REQUIREMENTS

• APPLICATION FOR EMPLOYMENT
• COMPETENCY TEST
• TWO FORM OF IDs (DL, PASSPORT & SS CARD)
• THREE-REFERENCE FROMS
• FACE TO FACE INTERVIEW FORM
• CRIMINAL BACKGROUND CHECK
• FBI BACKGROUND CHECK
• CHILD ABUSE BACKGROUND CHECK
• PHYSICAL EXAM/MEDICAL HISTORY
• CPR/FIRST AID
• PPD OR CHEST X-RAY
• PROFESSIONAL LICENSE OR CERTIFICATE
• COVID-19 VACCINE CRAD/WAIVER
• LIABILITY/MALPRACTICE INSURANCE IF APPLICABLE
• WORKER'S COMPENSATION INSURANCE IF APPLICABLE
• CONTRACTOR REGISTERED NAME/EIN IF APPLICABLE

BACKGROUND CHECK

STATE POLICE BACKGROUND CHECK FOR PENNSYLANIA RESIDENTS WHO RESIDE FOR TWO YEARS OR MORE.
FEDERAL BACKGROUND CHECK FOR OUT OF STATE RESIDENTS OR RESIDENTS WHO HAVE NOT RESIDE IN PENNSYLVINIA FOR MORE THEN TWO YEARS

I consent to the collection, use, storage, and processing of my personal and, where applicable, health-related information, including any data I submit on behalf of others, for the purpose of evaluating or fulfilling my request made through this form. I understand this will be handled in accordance with the Privacy Notice.