Application for Employment

Name*

First Last

Position(s) applied for or type of work desired:*

Address

Street Address Address Line 2 City State ZIP Code

Telephone #

Date you will be available to start work:

Do you have any objection to working overtime if necessary?

YES
NO

Can you travel if required by this position?

YES
NO

Have you ever been previously employed by our organization?

YES
NO

Can you submit proof of legal employment authorization and identity?

YES
NO

Have you ever been convicted of a crime in the last 7 years?

YES
NO

If yes, please explain (a conviction will not automatically bar employment):

Driver’s license number

Do you have a CDL?

YES
NO

If no CDL, would you be willing to get one?

How were you referred to us?

Employment History No. 1

Please provide all employment information for your past three employers starting with the most recent.

Employer:

Position held:

Address

Street Address Address Line 2 City State ZIP Code

Phone

Dates employed:

Salary:

Job summary:

Reason for leaving:

Employment History No. 2

Please provide all employment information for your past three employers starting with the most recent.

Employer:

Position held:

Address

Street Address Address Line 2 City State ZIP Code

Phone

Salary:

Dates employed:

Job summary:

Reason for leaving:

Other Skills and Qualifications

Summarize any job-related training, skills, licenses, certificates, and/or other qualifications:

Educational History

List school name and location, years completed, course of study, and any degrees earned:

High school:

College:

Technical Training:

Other:

References

List 3 references’ names, telephone numbers, and years known (do not include relatives or employers):

Consent*

I agree

I hereby authorize the potential employer to contact, obtain, and verify the accuracy of information contained in this application from all previous employers, educational institutions, and references. I also hereby release from liability the potential employer and its representatives for seeking, gathering, and using such information to make employment decisions and all other persons or organizations for providing such information.

I understand that any misrepresentation or material omission made by me on this application will be sufficient cause for cancellation of this application or immediate termination of employment if I am employed, whenever it may be discovered.

If I am employed, I acknowledge that there is no specified length of employment and that this application does not constitute an agreement or contract for employment. Accordingly, either I or the employer can terminate the relationship at will, with or without cause, at any time, so long as there is no violation of applicable federal or state law.

I understand that it is the policy of this organization not to refuse to hire or otherwise discriminate against a qualified individual with a disability because of that person’s need for a reasonable accommodation as required by the ADA.

I also understand that if I am employed, I will be required to provide satisfactory proof of identity and legal work authorization within three days of being hired. Failure to submit such proof within the required time shall result in immediate termination of employment.

I represent and warrant that I have read and fully understand the foregoing, and that I seek employment under these conditions.

Phone

This field is for validation purposes and should be left unchanged.

Now Hiring for PA & MD Location

717-400-5550

Now Hiring for PA & MD Location

717-400-5550