Volunteer Application
Personal Data
Name
*
First
Last
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County
Township
Home Phone Number
Please enter a valid phone number.
SSN #
*
Are you authorized to work in the United States?
*
Yes
No
Valid Driver's License?
*
Yes
No
Driver's Number
Expires
As a condition of employment you are required to submit proof of employment eligibility and identity in compliance with the Immigration & Reform Control Act of 1986
Are you under 18 years of age?
*
Yes
No
If yes, work permit?
Yes
No
Excluding any minor traffic violations, have you been convicted of any crime?
*
Yes
No
If so, explain
Please upload a copy of your driver's license or take a photo below
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Take Photo of Driver's License
According to state law, a criminal record check will be done
Please upload a copy of your background check if already obtained
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Employee Declaration
IN ACCORDANCE WITH PENNSYLVANIA PERSONAL CARE HOME REGULATIONS, I HEREBY CONFIRM THAT I HAVE NO HISTORY OF OR CONVICTION FOR A VIOLENT CRIME AND HAVE NEVER BEEN DISMISSED FROM EMPLOYMENT DUE TO THE ABUSE OF RESIDENTS. I DO NOT HAVE A MEDICAL CONDITION, INCLUDING DRUG OR ALCOHOL ADDICTION THAT PREVENTS ME FROM PERFORMING MY DUTIES WITH REASONABLE SKILL AND SAFETY.
Date
*
-
Month
-
Day
Year
Signature
*
Submit
Submit
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