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Application
First Name
*
Middle Name
Last Name
*
Email Address
*
Phone
*
Street Address
*
Apartment, suite, etc
*
City
*
State/Province
*
ZIP / Postal Code
*
Country
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Australia
Aruba
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cabo Verde
Cayman Islands
Central African Republic
Chad
Chile
China, People's Republic of
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
France, Metropolitan
French Guiana
French Polynesia
French South Territories
Gabon
Gambia
Georgia
Germany
Guernsey
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island And Mcdonald Island
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Johnston Island
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kosovo
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
North Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montserrat
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Reunion Island
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
Saint Helena
Saint Pierre & Miquelon
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and South Sandwich
Spain
Sri Lanka
Stateless Persons
Sudan
Sudan, South
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan, Republic of China
Tajikistan
Tanzania
Thailand
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks And Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
US Minor Outlying Islands
United States of America (USA)
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis And Futuna Islands
Western Sahara
Yemen
Zambia
Zimbabwe
REFERENCES
(LIST REFERENCES THAT ARE WORK RELATED OR PROFESSIONAL RELATIONSHIPS THAT CAN PROVIDE REFERENCES OF YOUR WORK)
1st REFERENCE
Name
Address
Phone
2nd REFERENCE
Name
Address
Phone
3rd REFERENCE
Name
Address
Phone
Do you have a PA driver’s license?
(If yes, write the number and expiration date:)
Upload ID
Remove
Date available for employment:
If you are not employed full time, are you interested in being placed on our waiting list?
*
Yes
No
Weekend employment
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Yes
No
Short-Term
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Yes
No
References:
Remove
References: Please attach photocopies of letters of reference and/or evaluations from work, college/university, supervisor and/or cooperating Co-Worker
Federal Privacy Act [5 U.S.C.§552A NOTE] Statement. Authority for requesting social security account numbers.
EDUCATIONAL BACKGROUND
1st EDUCATIONAL BACKGROUND
School or Institution and Location
Month and Year of Completion
Grade Point Average (GPA)
Diplomas, Degrees or Credits Earned
2nd EDUCATIONAL BACKGROUND
School or Institution and Location
Month and Year of Completion
Grade Point Average (GPA)
Diplomas, Degrees or Credits Earned
3rd EDUCATIONAL BACKGROUND
School or Institution and Location
Month and Year of Completion
Grade Point Average (GPA)
Diplomas, Degrees or Credits Earned
EXPERIENCE
(PRESENT OR MOST RECENT FIRST)
1st EXPERIENCE
Dates
From
Dates
To
Name of Employer and Address
Title
Work Performed:
Reason for Leaving:
Name & Title of Supervisor:
Final Yearly /Mon./Hourly Salary:
2nd EXPERIENCE
Dates
From
Dates
To
Name of Employer and Address
Title
Work Performed:
Reason for Leaving:
Name & Title of Supervisor:
Final Yearly /Mon./Hourly Salary:
GENERAL BACKGROUND INFORMATION
You must give complete answers to all questions. If you answer "Yes" to any question, you must list all offenses, and for each conviction provide the date of conviction and disposition, regardless of the date or location of occurrence. Conviction of a criminal offense is not a bar to employment in all cases. Each case is considered on its merits. Your answers will be verified with appropriate police records. Criminal Offense includes felonies, misdemeanors, summary offenses and convictions resulting from a plea of "nolo contendere" (no contest). A State of Pennsylvania Criminal Background Check Must be submitted with application. (Chapter 611.52. (a) Criminal Background Checks Conviction is an adjudication of guilt and includes determinations before a court, a district justice or a magistrate, which results in a fine, sentence or probation. You may omit: minor traffic violations, offenses committed before your 18th birthday which were adjudicated in juvenile court or under a Youth Offender Law, and any convictions which have been expunged by a court or for which you successfully completed an Accelerated Rehabilitative Disposition program.
Were you ever convicted of a criminal offense?
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Yes
No
Are you currently under charges for a criminal offense?
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Yes
No
Have you ever forfeited bond or collateral in connection with a criminal offense?
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Yes
No
Within the last ten years, have you been fired from any job for any reason?
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Yes
No
Within the last ten years, have you quit a job after being notified that you would be fired?
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Yes
No
Have you ever been professionally disciplined at/from work in any state?
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Yes
No
“Professionally disciplined” means the annulment, revocation or suspension from your work duties or having received a letter of reprimand from your work or suspended from pay? Note: If you answered "Yes" to any of the above questions, please provide a detailed explanation on a separate sheet of paper, including dates, and attach it to this application. Please print and sign your name on the sheet, and include your social security number.
ACT 34 Clearance (PA State Police Criminal Background Check)
Each applicant must submit with his/her employment application a copy of a Criminal History Record from the Pennsylvania State Police. Prospective employees must submit ORIGINAL report, which may not be more than one (1) month old. Submitted with application. (Chapter 611.52. (a) Criminal Background Checks) PCF is hereby authorized to acquire the same on behalf of the applicant.
ACT 114 (Federal Criminal History Record)
Each applicant must submit with his/her employment application a copy of a Federal Criminal Record from the Federal Bureau of Investigation (FBI). Prospective employees must submit ORIGINAL report, which may not be more than one (1) year old. (6 Pa.Code Ss 15.144(b) relating to procedures.) PCF is hereby authorized to acquire the same on behalf of the applicant.
ACT 151 Clearances (PA Child Abuse History Clearance)
Each candidate must submit with his/her employment application a copy of an official clearance from the Pennsylvania Department of Public Welfare. Prospective employees must submit ORIGINAL report, which may not be more than one (1) month old. (Chapter 611.53. (a) Criminal Background Checks Childline Registry.) PCF is hereby authorized to acquire the same on behalf of the applicant.
28 Pa. Code 611.51 Medical Clearances (611.56 Health Screening. Relating to hiring or rostering of Direct Care workers.)
Each candidate must submit with his/her employment application an ORIGINAL health report that clears him/her from Tuberculosis from a licensed Physician. Also, A Negative Covid Test prior to start employment. A Covid Vaccine proof is required. Original health report may not be more than (1) month old. PCF is hereby authorized to acquire the same on behalf of the applicant.
CERTIFICATION AND RELEASE AUTHORIZATION
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I certify that all of the statements made by me are true, complete and correct to the best of my knowledge and belief, and are made in good faith. I further certify that I am the sole author of the essay. I understand that any misrepresentation of information shall be sufficient cause for: (1) rejecting my candidacy, (2) withdrawing of any offer of employment, or (3) terminating my employment.
I hereby authorize any and all of my previous employers and/or supervisors to release any and all of my personnel records, and to respond fully and completely answer all questions those officials of PCF, LLC may ask regarding my prior work history and performance. I will hold such previous employers and/or supervisors harmless of any and all claims that I might otherwise have against them with regard to statements made to this Company... I further authorize these officials to investigate my background, now or in the future, to verify the information provided and release from liability all persons and/or entities supplying information regarding my background. Upload documents Criminal Background checks, transcripts, resume, PA Drivers license or ID, and copy of social security card.
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