Employment Application

Last Name:

First Name:

Middle Initial:

Date:

Street Address:

Apartment Number:

City:

State:

Zip Code:

Phone:

Email:

Date Available:

Social Security Number:

Desired Salary:

Position Applied For:

How were you referred to PWAC?

Full Time Employment Desired:

Select Full-Time

Part-time Employment Desired:

Select Part-Time

Are you a citizen of the United States?

Yes No

If no, are you authorized to work in the U.S?

Yes No

Have you ever worked for this company?

Yes No

If yes, when?

Have you ever been convicted of a felony?

Yes No

If yes, explain:

If relevant, please describe word processing speed, software knowledge, and office equipment experience:

If relevant, please describe experience using manufacturing machines and equipment:

List any relevant training programs completed:

High School:

High School Address:

High School From:

High School To:

Did you graduate from high school?

Yes No

High School Diploma:

College:

College Address:

College To:

College From:

Did you graduate from College?

Yes No

College Degree:

Other Education:

Other Education Address:

Other Education From:

Other Education To:

Did you graduate other education:

Yes No

Other Education Degree:

If required to drive a motor vehicle for the job applying for, state your"

Driver's License Number:

State Issued:

Driver's License Expiration Date:

Are you licensed with any group, association or society relating to the job for which you are applying?

Yes No

Registration or License Number:

What State Issued Your License?

Please list three professional references:

Professional Reference #1: Full Name

Professional Reference #1: Relationship

Professional Reference #1: Company

Professional Reference #1: Phone

Professional Reference #1: Address

Professional Reference #2: Full Name

Professional Reference #2: Relationship

Professional Reference #2: Company

Professional Reference #2: Phone

Professional Reference #2: Address

Professional Reference #3: Full Name

Professional Reference #3: Relationship

Professional Reference #3: Company

Professional Reference #3: Phone

Professional Reference #3: Address

Previous Employer #1: Company Name

Previous Employer #1: Phone

Previous Employer #1: Address

Previous Employer #1: Supervisor

Previous Employer #1: Job Title

Previous Employer #1: Starting Salary

Employer #1: Ending Salary

Previous Employer #1: Responsibilities

Previous Employer #1: Start Date

Previous Employer #1: End Date

Previous Employer #1: Reason for Leaving

May we contact your previous employer for a reference?

Yes No

Previous Employer #2: Company Name

Previous Employer #2: Phone

Previous Employer #2: Address

Previous Employer #2: Supervisor

Previous Employer #2: Job Title

Previous Employer #2: Starting Salary

Previous Employer #2: Ending Salary

Previous Employer #2: Responsibilities

Previous Employer #2: Start Date

Previous Employer #2: End Date

Previous Employer #2: Reason for Leaving

May we contact your previous employer for a reference?

Yes No

Previous Employer #3: Company Name

Previous Employer #3: Phone

Previous Employer #3: Address

Previous Employer #3: Supervisor

Previous Employer #3: Job Title

Previous Employer #3: Starting Salary

Previous Employer #3: Ending Salary

Previous Employer #3: Responsibilities

Previous Employer #3: Start Date

Previous Employer #3: End Date

Previous Employer #3: Reason for Leaving

May we contact your previous employer?

Yes No

All information contained in this application is true and correct to the best of my knowledge and belief. I understand that misrepresentations or omissions of any kind may result in denial of employment or be cause for subsequent dismissal if I am hired, regardless of when such information is discovered.

I authorize PWAC to investigate my responses on this application and contact any or all of my former employers or any individuals familiar with me or my employment background for the purpose of verifying any information I have provided and/or for the purpose of obtaining any information, whether favorable or unfavorable, about me or my employment. I voluntarily and knowingly fully release and hold harmless any person or organization providing information pertaining to me or my employment.
I understand that upon receiving a job offer, a physical examination and drug screening may be required. (Note: If this is a job requirement, you will be notified.)
I understand that prior to my employment I may be asked to sign a background consent form or other documentation in order to facilitate my hiring. I agree to sign these forms.

Regardless of whether or not I become employed by the company, I recognize that this application is not and should not be considered a contract of employment. I understand that the employment at the company is on an at-will basis and that my employment may be terminated with or without cause, and without notice, at any time, at my option or the company’s, unless specifically provided otherwise in a written employment contract. I further understand that no company employee or representative has the authority to enter into a contract regarding duration or terms and conditions of employment other than an officer or official of the company, and then only by means of a signed, written document.

I agree to the Disclaimer. Sign below.

Clear

Date

Please read and sign this form in the space provided below. Your written authorization is necessary for completion of the application process. I hereby authorize the Progressive Workshop of Armstrong County (PWAC) to investigate my background and qualifications (Act 33, Act 34 and DMV report) for the purpose of evaluating whether I am qualified for the position for which I am applying. I understand that PWAC will utilize an outside firm to assist in checking such information, and I specifically authorize such an investigation by information services and outside entities of the company's choice. I also understand that I may withhold my permission and that in such a case, no investigation will be done, and my application for employment will not be processed further.

Signature

Clear

Date

Printed Name

PWAC Employment Application

Applicant Information

Special Skills/Training Courses

Education

Required License(s)

References

Previous Employment

Disclaimer and Signature

Authorization for Background Check