Contact: Job Opportunities

Applicant Information
*First Name
Middle Initial
*Last Name
Date
Street Address
Apt./Unit Number
City
State
Zip
*Phone
Email
Position Applied For
Desired Salary
Have you ever worked for this company or Day Care Services, Inc.?	Yes No
If so, when?
Do you have any relatives that are or have been employed here?
If so, who?
Is there any reason that you could not obtain Act 34 & 151 clearances as required by DPW in Title 55 § 3270.192?	Yes No

Education
High School
Address
From
To
Did you graduate?	Yes No
Degree

College
Address
From
To
Did you graduate?	Yes No
Degree

Other
Address
From
To
Did you graduate?	Yes No
Degree

References please list three professional references
Full Name
Relationship
Company
Phone
Address

Full Name
Relationship
Company
Phone
Address

Full Name
Relationship
Company
Phone
Address

Previous Employment
Company
Phone
Address
Supervisor
Job Title
Starting Salary
Ending Salary
Responsibilities
From
To
Reason for Leaving
May we contact your previous supervisor for a reference?	Yes No

Company
Phone
Address
Supervisor
Job Title
Starting Salary
Ending Salary
Responsibilities
From
To
Reason for Leaving
May we contact your previous supervisor for a reference?	Yes No

Company
Phone
Address
Supervisor
Job Title
Starting Salary
Ending Salary
Responsibilities
From
To
Reason for Leaving
May we contact your previous supervisor for a reference?	Yes No

Military Service
Branch
From
To
Rank at Discharge
Type of Discharge
If other than honorable, explain
Disclaimer & Signature
I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in termination of my employment. The state of Pennsylvania is an "Employment at Will" state. Under this doctrine, absent a contract or other recognized exception to the contrary, an employee of a private sector employer can be terminated for good reason, bad reason, or no reason at all. When asked, we will make job applications available in alternative, accessible formats. We will also give assistance in completing the application. We only make pre-employment inquiries regarding an applicant's ability to perform the duties of the job.