APPLICATION FOR EMPLOYMENT

PLEA is an equal opportunity employer and will consider all applicants for all positions equally without regard to their race, sex, age, color, religion, national origin, veteran status or any disability as provided in the Americans With Disabilities Act.

Personal

First Name

Middle Initial

Last Name

Maiden

Date of Birth

Primary Phone

Alternative Phone

Mailing Address

City, State

Zip code

Social Security

Driver License State

Is your driver's license valid?

Are you over 18yrs old?

PA resident for at least 1 year?

Position Desired

Are You Seeking?

Willing to work part-time?

Minimal Salary Desired

Soonest start date:

Have you had any experience with children with special needs? If yes, please describe the situation(s).

How many hours per week are you available to work? (Hours/Week)

Are there any days or hours you would be unable or unwilling to work?

Specified days and/or hours unable to work

Can you work overtime?

If no, please explain

Do you have allergies that would prevent you from working in homes?

If yes, please explain

Would you be willing and able to physically pursue and restrain a child out of control?

If not, please explain:

How did you learn of our program and/or position?

Have you ever applied to PLEA before?

If Yes, please describe

Have you ever worked for PLEA before?

If Yes, please describe

Education

High School

High School Dates

High School Graduate?

Diploma Type

What College or University

College Dates

College Graduate?

Degree Type

What Graduate or Professional

Dates Attended

Graduate?

Degree Type

What Trade or Business School

Dates Attended

Graduate?

Degree Type

If you attended but did not graduate any of the above, please explain reasoning:

List any scholastic honors, offices held and activities involved in during high school and college

List and describe any other School or Specialized Training.

Are you planning to pursue further studies?

If so, when, where and what courses?

Will you abide by the safety rules of this agency?

How many days of work (or school) have you missed, other than for illness, in the last two years?

How many times have you been late for work (or school) in the last two years?

Are you able and willing to consistently report to work on time every day?

If no, please explain:

Work History

List names of employers in consecutive order with present or last employer listed first. Account for all periods of time including military service and any periods of unemployment. If self-employed, give firm name and supply business references.

Name of Employer

Dates Employed - Start Date:

Dates Employed - End Date:

City

State

Zip Code

Telephone Number

Nature of Business

No. Hrs Worked Per Week

Title

Pay - Starting: $

Pay - Ending: $

Name and Title of Last Supervisor

Reason for Leaving

Duties

Name of Employer

Dates Employed - Start Date:

Dates Employed - End Date:

City

State

Zip Code

Telephone Number

Nature of Business

No. Hrs Worked Per Week

Title

Pay - Starting: $

Pay - Ending: $

Name and Title of Last Supervisor

Reason for Leaving

Duties

Name of Employer

Dates Employed - Start Date:

Dates Employed - End Date:

City

State

Zip Code

Telephone Number

Nature of Business

No. Hrs Worked Per Week

Title

Pay - Starting: $

Pay - Ending: $

Name and Title of Last Supervisor

Reason for Leaving

Duties

Name of Employer

Dates Employed - Start Date:

Dates Employed - End Date:

City

State

Zip Code

Telephone Number

Nature of Business

No. Hrs Worked Per Week

Title

Pay - Starting: $

Pay - Ending: $

Name and Title of Last Supervisor

Reason for Leaving

Duties

Supplemental Employment Information

If you worked in any of your previous positions under another name, please give that name(s) below.
(For reference checking purposes.)

Name

Company

Are you presently employed:

If yes, may we contact your present employer?

Have you ever been disciplined for violating company safety rules or regulations?

If yes, please explain:

Have you filed any type of fraudulent claim against any of your present or past employers?

If yes, please explain:

Have you ever been fired, or asked to resign, from a job?

If yes, please explain:

Have you ever been disciplined or received verbal or written warnings for absenteeism or tardiness?

If yes, please explain:

Clearances

Do you have a current (less than 1 year old) clearance for the following:

Act 33 (Child Abuse) Clearance

Act 34 (Criminal History) Clearance

FBI Fingerprint Clearance

Have you ever been excluded from any Medicaid or Medicare work?

Have you ever been convicted of any crime (excluding minor traffic violations) including driving while under the influence of alcohol or drugs?

If yes, state the offense, location, date and disposition:

NOTE: A conviction will not necessarily disqualify you from employment.

Transportation

Do you have reliable transportation?

Do you have personal automobile insurance coverage?

How far are you willing to drive on assignments? (List number of miles traveling one way.)

References

Give three references, not relatives and at least one who can comment on your ability to work with children.

Name

Address

Phone

Relationship to Applicant

Name

Address

Phone

Relationship to Applicant

Name

Address

Phone

Relationship to Applicant

Affidavit

I certify that my answers to the foregoing questions are true and correct without any consequential omissions of any kind whatsoever. I understand that if I am employed, any false, misleading or otherwise incorrect statements made on this application form or during any interviews may be grounds for my immediate discharge.

I hereby authorize PLEA to contact any company or individual it deems appropriate to investigate my employment history, character and qualifications and I give my full and complete consent to their revealing any and all information they wish as a result of this investigation. In addition, I hereby waive my right to bring any cause of action against these individuals for defamation, invasion of privacy or any other reason because of their statements.

I agree that, if I am employed, I will abide by all the rules and regulations of the agency. I further understand that nobody in the agency is authorized to enter into any written or verbal employment contracts with me for any definite period of time without the express written consent of the Executive Director of the agency. I also understand that my employment is “ at-will” and may be terminated by myself or by the agency at any time for any reason or no reason at all, with or without prior notice.

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Date

(412) 243-3464

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APPLICATION FOR EMPLOYMENT

Personal

Education

Work History

Supplemental Employment Information

Clearances

Transportation

References

Affidavit

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