* = 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
EMPLOYMENT INFORMATION
Yes No
Yes No
1st 2nd 3rd
Availability:

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

Sunday


Monday


Tuesday


Wednesday


Thursday


Friday


Saturday

Yes No
Yes No
EMERGENCY CONTACT
EDUCATION
High School Education
College Education
Graduate School
EMPLOYMENT EXPERIENCE STARTING FROM YOUR MOST RECENT JOB
Employer 1
Yes No
(hourly/monthly/yearly)
Employer 2
Yes No
(hourly/monthly/yearly)
Employer 3
Yes No
(hourly/monthly/yearly)
REFERRENCES
Reference #1
Reference #2
Reference #3
AUTHORIZATION & AGREEMENT

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.

Yes No

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.