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PEP Job Application Form

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ladytkolofane
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© © All Rights Reserved
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31 views

PEP Job Application Form

Uploaded by

ladytkolofane
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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Employment Application

An Equal Opportunity Employer

Dear Applicant:
Thank you for your interest in pursuing career opportunities with Programs Employing People (PEP). A clear understanding of your background,
education, and employment history will enable us to best evaluate your qualifications. No question on this application is asked for the purpose of
limiting or excluding any applicant on the basis of race, color, sex, age, religion, ancestry, national origin, political beliefs, sexual orientation, or
disability.
Personal Information PLEASE FILL OUT IN DETAIL
Name: (Last, First, Middle) (Please Print) Application Date:

Address: (Street, City, State, Zip Code) Home Phone Number:


( )

How many years have you lived at his address? Cell Phone Number:
Have you lived in Pennsylvania for less than two years?  Yes  No ( )
Position(s) Applied for: Available for/ Preferred Hours: Email Address:
 Full-time  Part-time
 Day  Evening  Night
Date Available to Start: Salary Range Required:

How were you referred to  Advertisement  Friend/Relative  School  Other:


PEP? Publication: Name: Name:
Education PLEASE FILL OUT IN DETAIL
High School (Name and Location)

Program/Major: Did you graduate? GED?


 Yes  No  Yes
Higher Education (Name and Location)

Major/Degree: Did you graduate?


 Yes  No
Higher Education (Name and Location)

Major/Degree: Did you graduate?


 Yes  No
Please answer the following questions:
1. Are you 18 years of age or older?  Yes  No
2. Do you have a valid driver’s license?  Yes  No
3. Are you legally eligible for employment in the United States of America?  Yes  No
4. Are you willing to take a job-related test or physical exam?  Yes  No
5. Are you willing to work on a weekend or holiday if the job requires it?  Yes  No
6. Were you previously employed by PEP?  Yes  No
If yes, please indicate the program and dates:___________________________________________________________
7. Have you ever worked at PEP through a temporary staffing agency?  Yes  No
If yes, please indicate the program and dates: ___________________________________________________________
8. Can you speak, read and/or write any language other than English?  Yes  No
If yes, please specify the language(s): __________________________________________________________________
9. PA ODP regulations prohibit the employment in certain positions of persons with specific criminal convictions and/or  Yes  No
confirmed abuse of a dependent individual. Are you willing to undergo criminal record checks and child abuse clearance
as a precondition of your hire by PEP?
10. Do you have any physical and/or mental limitations that would preclude you from performing the work associated  Yes  No
with the position you are applying for?
11. Do you require any accommodations to perform the duties of the position you are applying for?  Yes  No
If yes, please describe: ______________________________________________________________________________
_________________________________________________________________________________________________
Employment Application

An Equal Opportunity Employer

Employment Complete entire application, regardless if your resume is attached. Start with your most
current position and list going back for your last four positions.
Dates (Month/Year-Month/Year) Employer (Name, Address, Phone Number)

Supervisor (Name and Title) Your Job Title and Major Duties:

Salary/Pay Rate: Reason for Leaving:

Dates (Month/Year-Month/Year) Employer (Name, Address, Phone Number)

Supervisor (Name and Title) Your Job Title and Major Duties:

Salary/Pay Rate: Reason for Leaving:

Dates (Month/Year-Month/Year) Employer (Name, Address, Phone Number)

Supervisor (Name and Title) Your Job Title and Major Duties:

Salary/Pay Rate: Reason for Leaving:

Dates (Month/Year-Month/Year) Employer (Name, Address, Phone Number)

Supervisor (Name and Title) Your Job Title and Major Duties:

Salary/Pay Rate: Reason for Leaving:

US Military Service?  Yes  No If yes, list branch(es) and any special training or experience:

Other human services, health, or educational If yes, please list where:


experience that is not listed above?
 Yes  No
Professional References
(List two; cannot be supervisors listed above)
Name, Address, and Phone Number Years Known: Individual’s Relationship to You:
1.

2.

Authorization and Release of Information


I hereby give PEP the right to make a thorough investigation of my past employment, education, and activities, and I release from all liability all
persons, companies and corporations supplying such information. I indemnify PEP against any liability which might result from making such an
investigation. I understand that any false answer or statement or implication made by me in this application or other required documents shall be
considered sufficient cause for denial of employment or discharge.

Additionally, I understand nothing contained in this employment application or in the granting of an interview is intended to create an employment
contract. No promises regarding employment have been made and I understand that no such promise or guarantee is binding upon PEP, unless
made in writing by the Executive Director.

Indicate other name (s) you have used at any time that are different from the name on this application: ___________________________________
_______________________________________________________________________________________________________________________

Print Name:

Signature: Date:

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