Professionals Form

* = Required Information

We consider applicants for all positions without any regard to race, color, religion, sex, national origin, age, marital or veteran status, the presence of a non-job related medical condition or handicap, or any other legally protected status.

PERSONAL INFORMATION

Name *

SSN

Current Address *

Apt #

City

State

Zip Code

Date of Birth *

Phone # 1 *

Phone # 2

Email *

EMPLOYMENT INFORMATION

Are you legally authorized to work in the United States?

Yes

Do you have a vehicle?

Yes

Driver's License or State ID #

What position are you applying for *

Preferred Shift *

1st

2nd

3rd

Availability:

Please indicate the Days and Times you are available to work:

Sunday

START TIME

END TIME

Monday

START TIME

END TIME

Tuesday

START TIME

END TIME

Wednesday

START TIME

END TIME

Thursday

START TIME

END TIME

Friday

START TIME

END TIME

Saturday

START TIME

END TIME

Have you filled out an application with us before?

Yes

Give date

Have you been employed with us before?

Yes

Give date

EMERGENCY CONTACT

Full Name *

Phone Number *

EDUCATION

High School Education

Name of School

Address of School

Year Completed

Major Area of Study

Diploma Awarded

College Education

Name of School

Address of School

Year Completed

Major Area of Study

Diploma Awarded

Graduate School

Name of School

Address of School

Year Completed

Major Area of Study

Diploma Awarded

EMPLOYMENT EXPERIENCE STARTING FROM YOUR MOST RECENT JOB

Employer 1

Employer Name

Dates Employed

Address

Phone #

Supervisor's Name

May we contact your supervisor

Yes

Title

Final Pay (hourly/monthly/yearly)

Reason for leaving

Employer 2

Employer Name

Dates Employed

Address

Phone #

Supervisor's Name

May we contact your supervisor

Yes

Title

Final Pay (hourly/monthly/yearly)

Reason for leaving

Employer 3

Employer Name

Dates Employed

Address

Phone #

Supervisor's Name

May we contact your supervisor

Yes

Title

Final Pay (hourly/monthly/yearly)

Reason for leaving

REFERRENCES

Reference #1

Name

Referrence Location

Business

Phone Number

Number of Year Known

Reference #2

Name

Referrence Location

Business

Phone Number

Number of Year Known

Reference #3

Name

Referrence Location

Business

Phone Number

Number of Year Known

AUTHORIZATION & AGREEMENT

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 investigation of all statements contained herein and the references listed above to give you any and all information concerning my previous employment and any pertinent information they may have personal or otherwise, and release all parties from all liability for any damage that may result from furnishing same to you.

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

In accordance w/ State regulatory boards SSS shall obtain a limited criminal history for each employee, officer, or agent involved in the management, administration, or provision of services. A criminal history check will be conducted with the State Police and/or any other appropriate law enforcement agencies. If a candidate answers "yes" to the criminal conviction question, we may complete the criminal history check and consider its job relatedness prior to extending an employment offer.

Have you ever pleaded guilty or been convicted of an offense described in this section?

Yes

Please describe

CHILD ABUSE CHECK - We will conduct a child abuse check with the PA Department of Public Welfare and/or other appropriate agencies dealing with child welfare issues.

DRIVER'S LICENSE CHECK - In positions where driving is a requirement for the position, SSS will conduct a driver's license check prior to employment and periodically thereafter to verify the validity of the license and to address issues regarding safety and safe driving.

EMPLOYMENT VERIFICATION CHECK - SSS will conduct employment verifications with the candidate's current and previous employers regardless of the relevance of the employment to the human services field.

PERSONAL REFERENCE - Where appropriate or required by regulatory standards, personal references will be conducted.

I have read and I understand the above information. I further understand that any offer of employment is conditional, based on the successful completion of all applicable background checks and post offer employment physical to include drug screening. I certify and declare that all statements herein are true and understand that any falsification, misrepresentation or omission of a fact in this application shall be sufficient cause for SSS to refuse to hire me or for dismissal; in the event that the falsification, misrepresentation or omission is discovered after I have been hired.