PERSONAL INFORMATION

First Name: Middle Initial: Last Name:

Street Address:

City: State: Zip Code:

Social Security: - - * optional ( Must be provided at interview )

Telephone:

Home - -

Mobile - -

U.S. Citizen:
Yes
No

If “No”, do you have a valid work permit?
Yes
No

Are you a resident of Pennsylvania?
Yes
No
If yes, How long? years

Are you at least 18 years of age?
Yes
No

Do you have a valid driver’s license?
Yes
No
Lic#
State: Not Selected Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Do you have reliable transportation?
Yes
No

Have you had any accidents in the past 3 years?
Yes
No
If so, how many?

Have you had any moving violations in the past 3 year?
Yes
No
If so, how many?

Is anyone currently employed by our agency a relative?
Yes
No
List name and relationship below:

EDUCATION

Name and Address of Educational Institution, Dates Attended, Credits Diploma/Degree Major :

College/University:

From: Not Selected January February March April May June July August September October November December Not Selected 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 before 1990 To: Not Selected January February March April May June July August September October November December Not Selected 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 before 1990

Degree and Major:

Professional/Graduate:

From: Not Selected January February March April May June July August September October November December Not Selected 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 before 1990 To: Not Selected January February March April May June July August September October November December Not Selected 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 before 1990

Degree and Major:

Other Schooling (Specify):

From: Not Selected January February March April May June July August September October November December Not Selected 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 before 1990 To: Not Selected January February March April May June July August September October November December Not Selected 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 before 1990

Degree and Major:

EMPLOYMENT HISTORY

Please list names of employers in order with present or last employer listed first.

Employer Name:

Address:

Rate of Pay:

Number of Hours worked per week:
hrs.

Telephone#:

Immediate Supervisor:

Duties and Responsibilities:

Reason For Leaving:

May We Contact Employer:
Yes
No

Dates of employment ( month / year ):
From: Not Selected January February March April May June July August September October November December Not Selected 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 before 1990 To: Not Selected January February March April May June July August September October November December Not Selected 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 before 1990

Employer Name:

Address:

Rate of Pay:

Number of Hours worked per week:
hrs.

Telephone#:

Immediate Supervisor:

Duties and Responsibilities:

Reason For Leaving:

May We Contact Employer:
Yes
No

Dates of employment ( month / year ):
From: Not Selected January February March April May June July August September October November December Not Selected 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 before 1990 To: Not Selected January February March April May June July August September October November December Not Selected 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 before 1990

Employer Name:

Address:

Rate of Pay:

Number of Hours worked per week:
hrs.

Telephone#:

Immediate Supervisor:

Duties and Responsibilities:

Reason For Leaving:

May We Contact Employer:
Yes
No

Dates of employment ( month / year ):
From: Not Selected January February March April May June July August September October November December Not Selected 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 before 1990 To: Not Selected January February March April May June July August September October November December Not Selected 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 before 1990

PAST HISTORY:

“Previous convictions are not necessarily a bar to employment. All information will be considered on a case by case basis.”

Have you ever been convicted of a criminal offense? (Do not include minor traffic citations or offenses committed before age 18.)
Yes
No

If yes, provide details such as nature of offense (felony, misdemeanor, etc), date, etc.

Are there any criminal charges pending?
Yes
No

If “yes”, provide details below

REFERENCES

Please provide three personal references (Not Relatives and have known over five years)

Address:

( City, State, Zip )

Phone #

Name:

Address:

( City, State, Zip )

Phone #

Name:

Address:

( City, State, Zip )

Phone #

Can you work Weekends?
Yes
No

Can you sleep overnight?
Yes
No

Can you work holidays?
Yes
No

Are you seeking part-time or full-time employment?
Part Time
Full Time

How did you hear about our agency?

I certify that the information above is correct to the best of my knowledge and belief. I am aware that any false or misleading statements contained herein will be considered grounds for dismissal. All information above will be verified.

***All Applicants must submit to post-offer urine drug screening as a condition of their continued employment***

Signature:

Date: Not Selected January February March April May June July August September October November December Not Selected 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Not Selected 2011