Employment Application Name* First Middle Initial Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email Position DesiredDate available to begin workPay ExpectedShift Desired Full Time Part Time Have you ever applied for employment with us? Yes No If yes, when?How did you learn of our organization? Walk-in Advertisement Website Referral Other If other, please specifyHave you lived outside of Pennsylvania in the last 2 years? Yes No If yes, please specify which stateAre you over the age of 18 years? Yes No (If no, you are required to provide authorization to work)Are you currently employed? Yes No May we contact your current employer?Are you able to perform the essential functions of the job for which you are applying, with or without a reasonable accommodation? Yes No Are you legally eligible to work in the United States? Yes No (If offered employment, you will be required to provide documentation to verify eligibility.)State names of relatives and friends working at Reformed Presbyterian Home:List any special training or skillsDo you hold any current professional license? Yes No If yes, please describe:Have you <u>ever</u> been convicted of a violent crime in the past 10 years, excluding misdemeanors and summary offenses, which has not been annulled, expunged, or sealed by a court? Yes No Have you <u>ever</u> been dismissed from employment due to abuse or neglect of clients or residents? Yes No Have you <u>ever</u> been convicted of a felony offense or two or more misdemeanors? Yes No EducationEmployment HistoryEmployer NameEmployer PhoneEmployer Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Name and Title of SupervisorJob Title & DescriptionEmployment Dates:Reason for leavingEmergency Contact InformationWho would you like us to contact in an emergency?Name* First Last Relationship*Home Phone #*Cell Phone #ReferencesPlease list two references.Name*Relationship*PhoneEmail Name*Relationship*PhoneEmail AvailabilityAnything else you'd like us to know about you: I hereby certify that the facts set forth in the above employment application are true and complete to the best of my knowledge and authorize RPWA to verify their accuracy and to obtain reference information on my work performance. I hereby release RPWA from any/all liability of whatever kind and nature which, at any time, could result from obtaining and having an employment decision based on such information. I understand that, if employed, falsified statements of any kind or omissions of facts called for on this application shall be considered sufficient basis for dismissal. I understand that should an employment offer be extended to me and accepted by me, I will filly adhere to the policies, rules, and regulations of employment of the RPWA. I further understand that neither the policies, rules, regulations of employment or anything said during the interview process shall be deemed to constitute the terms of an implied employment contract. I understand that any employment offered is for an indefinite duration at will, and that either I or the RWPA may terminate my employment at any time with our without notice or cause. By entering my name below, I am signing this application.* Yes Enter your name as signature*This employment application is only valid for 180 days from the date submitted.PhoneThis field is for validation purposes and should be left unchanged.
