Employment

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APPLICATION FOR EMPLOYMENT (PA)

Equal Employment Opportunity Policy: We are committed to providing equal employment opportunities to all employees and applicants without regard to race, religion, color, sex, national origin, citizenship status, uniform member status, age, creed, ancestry, use of a guide or support animal, disability or any other protected status in accordance with all applicable federal, state, and local laws.

Position Desired

Date

First/Last/Middle
/ /

Present Address

Street and Number/City/State/Zip - How long at Present Address
/ / / - yrs.months.

Previous Address

Street and Number/City/State/Zip - How long at Previous Address
/ / / - yrs.months.

Telephone No.

Email Address:

Note: Answering "Yes" to the following four questions does not constitute an automatic bar to employment. Factors such as age and time of the offense, seriousness and nature of the violation, and rehabilitation will be taken into account. (Do not include minor traffic citations and arrests or convictions which have been sealed or expunged in answering this question.)

Have you ever worked for this company before?

If Yes please give dates and position

Have you ever pled guilty, or no contest to, or been convicted of a felony?

If Yes please give dates and details

Have you ever pled guilty, or no contest to, or been convicted of a misdemeanor resulting in imprisonment within the last seven years?

If Yes please give dates and details

Have you been arrested for any matters for which you are out on bail or on your own recognizance pending trial?

If Yes please give dates and details

Record of Previous Employment
Please list the name of your present or previous employers in chronological order with present or last employer listed first. Be sure to account for all periods of time including military service and any period of unemployment. If self-employed, give firm name and supply business references.

Present or Last Employer	Address	City, State, Zip	Telephone
Employed (From/To)	Pay (Start/Finish)	Title or Position	Name and Title of Supervisor
Exact Reason for Leaving

Present or Last Employer	Address	City, State, Zip	Telephone
Employed (From/To)	Pay (Start/Finish)	Title or Position	Name and Title of Supervisor
Exact Reason for Leaving

Present or Last Employer	Address	City, State, Zip	Telephone
Employed (From/To)	Pay (Start/Finish)	Title or Position	Name and Title of Supervisor
Exact Reason for Leaving

Have you ever been terminated or asked to resign from any job?

If Yes please explain the circumstances

Please explain fully any gaps in your employment history:

May we contact your current employer?

If No, please explain:

Please indicate any actual experience, special training and qualifications that you have which you feel are relevant to the position for which you are applying.

Have you ever used another name?

Is any additional information relative to change of name, use of an assumed name, or nickname necessary to enable a check on your work and educational record? If yes, please explain.

If hired can you furnish proof that you are over 18 years of age?

Do you have adequate transportation to and from work?

How many days of work have you missed in the last three years due to reasons other than paid holidays and vacation?

YearDays / / YearDays / / YearDays

Education
School Name:	Years Completed	Diploma/Degree	Course of Study/Major	Specialized Training, Skills, or Extra-Curricular Activities
High School
College/Univ.
Grad/Professional
Trade or Correspondence
Other :
Other :

Personal References Please list persons who know you well - exclude previous employers or relatives
Name	Occupation	Address (Street, City, State)	Telephone Number	Number of Years Known




I CERTIFY THAT ALL OF THE INFORMATION THAT I HAVE PROVIDED ON THIS APPLICATION IS TRUE AND ACCURATE. This application will be considered active for a maximum of thirty (30) days. If you wish to be considered for employment after that time you must reapply.