EMPLOYMENT APPLICATION

Employment Application
Personal Information
Name*

First NameLast Name
Date*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
SSN*
DOB*

MonthDayYear
Date
Date Available

MonthDayYear
Date
Desired Pay: $
HourlySalary
Position Applied For:
Employment Desired

Full-TimePart-TimeSeasonal

Employment Eligibility
Are you legally eligible to work in the US?*

YesNo
Have you ever worked for this employer?*

YesNo
If you have worked for this employer, enter the Start Date Date and End Date Date .
Have you ever been convicted of a felony?*

YesNo
If yes, please explain: Type a label .

Education
High School: School Name

City / State: Allentown, PA

From: Date To: Date
Graduate?

YesNoOther
College: School Name

City / State: Allentown, PA

From: Date To: Date
Graduate?

YesNoOther
Other: School Name

City / State: Allentown, PA

From:   Date   To:   Date


Degree/Certificate:   Type a label

Previous Employment
Employer 1:
Phone Number
Please enter a valid phone number.
Employer Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Starting Pay: $

Ending Pay: $

Job Title: blanks

Responsibilities: blank

From:   Date   To:   Date

Reason for Leaving:   Type a label
Employer 2:
Phone Number
Please enter a valid phone number.
Employer Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Starting Pay: $

Ending Pay: $

Job Title: blanks

Responsibilities: blank

From:   Date   To:   Date

Reason for Leaving:   Type a label

References

(Professional Only)
Full Name:   First Name   Last Name   Relationship: Coworker
Company:      Title:   Manager   Email:   Email
Phone:   (000)   000-0000
Full Name:   First Name   Last Name   Relationship: Coworker
Company:      Title:   Manager   Email:   Email
Phone:   (000)   000-0000
Full Name:   First Name   Last Name   Relationship: Coworker
Company:      Title:   Manager   Email:   Email
Phone:   (000)   000-0000

Background Check Consent
If asked, are you willing to consent to a background check?*

YesNo
Disclaimer
Applicant understands that this is an Equal Opportunity Employer and committed to excellence through diversity. In order to ensure this application is acceptable, please print or type with the application being fully completed in order for it to be considered.

Please complete each section EVEN IF you decide to attach a resume.

I, the Applicant, certify that my answers are true and honest to the best of my knowledge. If this application leads to my eventual employment, I understand that any false or misleading information inmy application or interview may result in my employment being terminated.
Signature*

Clear
Date

MonthDayYear
Date
Full Name

First NameLast Name
PHILADELPHIA AGENCIES MUST REMOVE THIS SECTION (Ban the box legislation)
Have you been charged/convicted of a Felony or Misdemeanor or served time

YesNo
If yes, Incidentblanks City/State blank Charge: Type a label
If yes, Incident blanks City/State blank Charge: Type a label
Have you ever been a charged perpetrator or appeared on any child abuse registry in the last 5 years?

YesNo

Disclaimer

Applicant Notice
It is illegal in Philadelphia for employers to ask about your criminal background during the job application process.

Employers cannot ask about your criminal background on job applications or during any job interview. Employers can run your criminal background check ONLY AFTER a conditional offer of employment is made (final hiring depend on the results of your background check).
- Criminal convictions can be considered ONLY if they occurred less than 7 years fromwhen you apply (not counting time of incarceration).
- Arrests that did not lead to conviction cannot be used in any employment decisions.
- If your background check reveals a conviction, the employer must consider:
  The type of offense and the time that has passed since it occurred.
  Its connection to the job you’re applying for; and
- Your job history, character references, and any evidence of rehabilitation.
- Employers can reject you based on your criminal record ONLY if you pose an
  unacceptable risk to the business or to other people.
- If you are rejected, the employer must send the decision to you in writing with a copy of the background report used to make the decision.
- You have 10 days to give an explanation of your record, proof that it is wrong, or proof of rehabilitation.
Disclaimer

Applicant Certification and Release
I certify that I have read and understand the applicant note on page one (1) of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief.

I understand that any false information, omissions or misrepresentations of facts in this application may result in rejection of my application or discharge at any time during my employment. I authorize the company and/or its agents, including consumer-reporting bureaus, to verify any of this information including, but not limited to, criminal history and motor vehicle driving records. I authorize all persons,
schools, companies and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I release this company from any liability which might result from making such investigations.

I also understand that the use of illegal drugs is prohibited during employment. I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment. I understand that this application is not a contract of employment. My employment is contingent upon confirmation of credentials and successful completion of drug test or criminal background check. I also understand that if hired, regardless of any oral presentations to the contrary, the employment relationship between the Company and myself is terminable at-will, so that both the company and I remain free to choose to end out work relationship at any time for any or no reason. Any changes in this employment relationship must be made in writing. My signature below acknowledges that I have read, understand, and agree to the above disclosure. I also understand that due to the nature of the business, no amount of work can be guaranteed.
Signature

Clear
Date

MonthDayYear
Date

DIRECT CARE WORKER AVAILABILITY FORM

Please complete the following schedule and provide times that you are able to work for CAAHC. We provide services 24 hours a day, 7 days a week. How you complete this form is especially important. The work hours that are provided for you by CAAHC are driven by two primary business issues; the needs of the Consumers and your availability to work.
Total requested hours per week:

Ideal: Minimum: Maximum:
**l understand that the more I am available to work the greater likelihood that my hours request will be met.

Availability

	AM	PM
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

Are you willing to do temporary fill-in hours?
Are you available to be On-Call for additional income?
Are you willing to work with Consumers who smoke?
Are you willing to work with Consumers who have pets?
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Employment Application

Personal Information

Employment Eligibility

Education

Previous Employment

References

Background Check Consent

Disclaimer

Disclaimer

Disclaimer

DIRECT CARE WORKER AVAILABILITY FORM

Total requested hours per week: