English Application Package

Application for employment

General Information
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState & Zip Code

Postal / Zip Code
Email*
example@example.com
Phone Number*
Phone #
Are you legally entitled to work in the US?*
Are you able to perform the essential job functions?*
Salary Desired?*
Date available to start working?*

MonthDayYear
Date
Veteran Information
Branch of service?
Special Skills?
Work Experience
Name of Most Recent Employer
Employer Phone Number
Employer Address
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Specific Duties Performed
May we contact this employer?

YesNo
Reason for leaving?
Name of 2nd Most Recent Employer
Employer Phone Number
Please enter a valid phone number.
Employer Address
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Specific Duties Performed
May we contact this Employer?

YesNo
Reason for leaving?
Name of 3rd Most Recent Employer
Employer Phone Number
Please enter a valid phone number.
Employee Address
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Specific Duties Performed
May we contact this Employer?

YesNo
Reason for leaving?
Referral
Were you referred to us by a current EHC employee? If so, who?
Certificates & Licenses

Do you have any of the following licenses/certificates? If you have others not mentioned, please list them in the other area. Please upload a copy of all current licenses you've listed you have.

	Yes/Si	No
OSHA 10 Hour
OSHA 30 Hour
OSHA 40 Hour
Asbestos License
Lead License
DOT Physical

Other Licenses or Certificates held
Upload Image of all Certificates/Licenses noted above

Cancelof
Upload Resume

Cancelof
Applicant's Signature

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Date Signed

MonthDayYear
Date

ACT 114 Federal Criminal History Record
Name

First NameLast Name
Middle Name
Place of Birth (State) - Add Country if born outside of the US
City of Birth
Date of Birth

MonthDayYear
Date
Social Security Number
Eye Color
Hair Color
Height*
Weight
Country of Citizenship*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Driver's License Number
Street Address
City
State*
Zip Code*
Phone Number*

COMMONWEALTH OF PENNSYLVANIA SEXUAL MISCONDUCT/ABUSE DISCLOSURE RELEASE
This standardized form has been developed by the Pennsylvania Department of Education, pursuant to Act 168 of 2014, to be used by school entities and independent contractors of school entities and by applicants who would be employed by or in a school entity in a position involving direct contact with children to satisfy the Act's requirement of providing information related to abuse or sexual misconduct. As required by Act 168, in addition to fulfilling the requirements under section 111 of the School Code and the Child Protective Services Law ("CPSL"), an applicant who would be employed by or in a school entity in a position having direct contact with children, must provide the information requested in SECTION 1 of this form and complete a written authorization that consents to and authorizes the disclosure by the applicant's current and former employers of the information requested in SECTION 2 of this form. The applicant shall complete one form for the applicant's current employer(s) and one for each of the applicant's former employers that were school entities or where the applicant was employed in a position having direct contact with children (therefore, the applicant may have to complete more than one form Upon completion by the applicant, the hiring school entity or independent contractor shall submit the form to the applicant's current and former employers to complete SECTION 2. A school entity or independent contractor may not hire an applicant who does not provide the required information for a position involving direct contact with children.

Direct Contact with Children is defined as: "the possibility of care, supervision, guidance or control of children or routine interaction with children."

Sexual Misconduct is defined as: "any act, including, but not limited to, any verbal, nonverbal, written or electronic communication or physical activity, directed toward or with a child or a student regardless of the age of the child or student that is designated to establish a romantic or sexual relationship with the child or student. Such acts include, but are not limited to: (1) sexual or romantic invitation; (2) dating or soliciting dates; (3) engaging in sexualized or romantic dialogue; (4) making sexually suggestive comments; (5) self-disclosure or physical exposure of a sexual, romantic or erotic nature; or (6) any sexual, indecent, romantic or erotic contact with the child or student." Abuse is defined as "conduct that falls under the purview and reporting requirements of the CPSL, 23 Pa.C.S. Ch. 63, is directed toward or against a child or a student, regardless of the age of the child or student."

A prospective employer that receives any requested information regarding an applicant may use the information for the purpose of evaluating the applicant's fitness to be hired or for continued employment and shall report the information as appropriate to the Department of Education, a state licensing agency, law enforcement agency, child protective services agency, another school entity or to a prospective employer. If the prospective employer decides to further consider an applicant after receiving an affirmative response to any of the questions listed in SECTIONS 1 and 2 of this form, the prospective employer shall request that former employers responding affirmatively to the questions provide additional information about the matters disclosed and include any related records. The Commonwealth of Pennsylvania Sexual Misconduct/Abuse Disclosure Information Request can be used to request this follow-up information. Former employers shall provide the additional information and records within 60 calendar days of the prospective employer's request. The completed form and any information or records received shall not be considered public records for the purposes of the Act of February 14, 2008 (P.L. 6, No. 3) known as the "Right to Know Law." The Department of Education shall have jurisdiction to determine willful violations of Act 168 and may, following a hearing, assessa civil penalty not to exceed $10,000. School entities shall be barred from entering into a contract with an independent contractor who is found to have willfully violated the provisions of Act 168.

COMMONWEALTH OF PENNSYLVANIA SEXUAL MISCONDUCT/ABUSE DISCLOSURE RELEASE
Section 1: Applicant Certification and Release (to be completed by the applicant even if the applicant has no current or prior employment to disclose)
Applicants Name (First, Middle, Last)
Any former names by which the Applicant has been identified*
Date of Birth
Last 4 digits of Applicants Social Security Number
PPID if applicable
Approximate dates of employment with the entity listed above

MonthDayYear
Date
Positions held with the entity
Pursuant to Act 168, an employer, school entity, administrator, and/or independent contractor that provides information or records about a current or former employee or applicant shall be immune from criminal liability under the CPSL, the Educator Discipline Act, and from civil liability for the disclosure of the information, unless the information or records provided were knowingly false. Such immunity shall be in addition to and not in limitation of any other immunity provided by law or any absolute or conditional privileges applicable to such disclosure by the virtue of the circumstances of the applicant's consent thereto. Under Act 168, the willful failure to respond to or provide the information and records as requested may result in civil penalties and/or professional discipline, where applicable.

Have you ever been the subject of an abuse or sexual misconduct investigation by any employer, state licensing agency, law enforcement agency or child protective services agency (unless the investigation resulted in a finding that the allegations were false)?

YesNo
Have you ever been disciplined, discharged, non-renewed, asked to resign from employment, resigned from or otherwise separated from employment while allegations of abuse or sexual misconduct were pending or under investigation or due to adjudication or findings of abuse or sexual misconduct?

YesNo
Have you ever had a license, professional license or certificate suspended, surrendered or revoked while allegations of abuse or sexual misconduct were pending or under investigation or due to an adjudication or findings of abuse or sexual misconduct?

YesNo
By signing this form, I certify under penalty of law that the statements made in this form are correct, complete, and true to the best of my knowledge. I understand that false statements herein, including, without limitation, any willful failure to disclose the information required, shall subject me to criminal prosecution under 18 Pa.C.S. § 4904 (relating to unsworn falsification to authorities) and to discipline up to, and including, termination or denial of employment, and may subject me to civil penalties and disciplinary action under the Educator Discipline Act. I also hereby authorize the above-named employer to release to the entity listed on page 3, the information requested in SECTION 2 of this form and any related records. I hereby release, waive, and discharge the above-named employer from any and all liability of any kind that may arise from such disclosure or release of records. I understand that third party vendors may be used to process this Act 168 pre-employment history review.
Signature

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Date

MonthDayYear
Date
SECTION 2: Completed by EHC Associates

ARREST/CONVICTION REPORT AND CERTIFICATION FORM

(under Act 24 of 2011 and Act 82 of 2012)

Section 1.Personal Information/Informacion personal
Full Legal Name
Other names you have gone by
Date of Birth

MonthDayYear
Date
Section 2: Arrest or Conviction

By checking this box, I state that I have NOT been arrested for or convicted of any Reportable Offense.By checking this box, I report that I have been arrested for or convicted of an offense or offenses enumerated under 24 P.S.
If you checked the second box that you have been arrested or convicted of an offense, please list the offense, date, location, docket number and applicable court location of each arrest/conviction below.
Section 3: Child Abuse

By checking this box, I state that I have NOT been named as a perpetrator of a founded report of child abuse within the pastfive (5) years as defined by the Child Protective Services Law.By checking this box, I report that I have been named as a perpetrator of a founded report of child abuse within the past five (5) years asdefined by the Child Protective Services Law.
Section 4. Certification

By signing this form, I certify under penalty of law that the statements made in this form are true, correct and complete. I understand that false statements herein, including, without limitation, any failure to accurately report any arrest or conviction for a Reportable Offense, shall subject me to criminal prosecution under 18 Pa.C.S. $4904, relating to unsworn falsification to authorities.
Applicant Signature

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Date of Signing

MonthDayYear
Date

Pursuant to 24 P.S. §1-111(c.4) and (j), the Pennsylvania Department of Education developed this standardized form (PDE-6004) to be used by current and prospective employees of public and private schools, intermediate units, and area vocational-technical schools.

As required by subsection (c.4) and (j2) of24P.S.1-111, this form shallbecompletedandsubmitted by all current and prospective employees of said institutions to provide written reporting of any arrest or conviction for an offense enumerated under 24 P.S. §§1-111(e) and (f.1) and to provide notification of having been named as a perpetrator of a founded report of child abuse within the past five (5) years as defined by the Child Protective Services Law.

As required by subsection (j4) of 24 P.S. §1-111, this form also shall be utilized by current and prospective employees to provide written notice within seventy-two (72) hours after a subsequent arrest or conviction for an offense enumerated under 24 P.S. §§1-111(e) or (f.1).

In accordance with 24 P.S. §1-111, employees completing this form are required to submit the form to the administrator or other person responsible for employment decisions in a school entity. Please contact a supervisor or the school entity administration office with any questions regarding the PDE 6004, including to whom the form should be sent.

PENNSYLVANIA CHILD ABUSE HISTORY CERTIFICATION
ehc Associates requires these clearances for jobs that require the employees to do work inside school facilities. All employees must have the same clearances as a school employee does to be able to be onsite for a project on school property.
Consent/Release

Consent/Release of Information Authorization form is attached. Applicant must fill in the "Other Address" sections. By completing the other address sections, you are agreeing that the organization will have access to the status and outcome of your certification application.
Applicant Demographic Information
Name

FIRST NAMEMIDDLE NAMELAST NAMESUFFIX
Social Security Number
Gender

MaleFemaleNot Reported
DATE OF BIRTH

MonthDayYear
Date
AGE
Disclosure of your Social Security number is voluntary. It is sought under 23 Pa.C.S. §§ 6336(a1) (relating to information in statewide database), 6344 (relat- ing to employees having contact with children; adoptive and foster parents), 6344.1 (relating to information relating to certified or licensed child-care home residents), and 6344.2 (relating to volunteers having contact with children The department will use your Social Security number to search the statewide database to determine whether you are listed as the perpetrator in an indicated or founded report of child abuse.
HOME ADDRESS
ADDRESS LINE 1
ADDRESS LINE 2
CITY
COUNTY
STATE
ZIP CODE
COUNTRY
MAILING ADDRESS

(if different from home address)
ADDRESS LINE 1
ADDRESS LINE 2
CITY
COUNTY
STATE
ZIP CODE
COUNTRY
ATTENTION
CONTACT INFORMATION
Home Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Email address
example@example.com

PENNSYLVANIA CHILD ABUSE HISTORY CERTIFICATION
PREVIOUS NAMES USED SINCE 1975

(Include maiden name, nickname and aliases)
1.) Previous name used:

First NameMiddle NameLast NameSuffix
2.) Previous name used:

First NameMiddle NameLast NameSuffix
3.) Previous name used:

First NameMiddle NameLast NameSuffix
4.) Previous name used:

First NameMiddle NameLast NameSuffix
5.) Previous name used:

First NameMiddle NameLast NameSuffix
PREVIOUS ADDRESSES SINCE 1975

(Please list all addresses since 1975, partial address acceptable)
1.) Most recent address prior to your current address:
2.) Next most recent address
3.) Next most recent address
4.) Next most recent address
5.) Next most recent address
6.) Next most recent address
7.) Next most recent address
HOUSEHOLD MEMBERS

Please list everyone who lived with you at any time since 1975 to present. A parent, guardian or someone who raised you must be included even if they don't currently live with you.

	Name (First, Middle, Last)	Relationship?	Current Age	Gender
1.)
2.)
3.)
4.)
5.)
6.)
7.)
8.)
9.)
10.)

I affirm that the above information is accurate and complete to the best of my knowledge and belief and submitted as true and correct under penalty of law (Section 4904 of the Pennsylvania Crimes Code If I selected volunteer, I understand that I can only use the certificate for volunteer purposes.
APPLICANTS SIGNATURE

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DATE of Signing

MonthDayYear
Date
Should be Empty:

SECTION 2: Completed by EHC Associates

PENNSYLVANIA CHILD ABUSE HISTORY CERTIFICATION

HOME ADDRESS

MAILING ADDRESS

CONTACT INFORMATION

PENNSYLVANIA CHILD ABUSE HISTORY CERTIFICATION

HOUSEHOLD MEMBERS