EMPLOYMENT APPLICATION

Pento Homecare Agency 724-322-1683

54A Lebanon AveUniontown, PA 15401

Pento Homecare Agency does not discriminate on the basis of race, color, national origin, ancestry, religious creed, handicap, or age as stated in the Pennsylvania Human Relations Act of 1955.

PLEASE PRINT AND COMPLETE THE ENTIRE APPLICATION. IF ANY OF THE FOLLOWING QUESTIONS ARE NOT ANSWERED IN A COMPLETE AND ACCURATE FASHION, A SIGNIFICANT DELAY AND / OR THE INABLILITY TO PROCESS THIS APPLICATION MAY OCCUR.

Date*

Date

Name*

FIRST NAMELAST NAME

MAIDEN / PRIOR ALIASES

ADDRESS*

CITY STATE ZIP*

PHONE*

CELL*

POSITION APPLIED FOR*

Available to work:*

Full TimePart TimeTemporary

IF TEMPORARY, PLEASE EXPLAIN

ARE THERE ANY DAYS OR HOURS YOU WOULD BE UNABLE OR UNWILLING TO WORK?*

YesNo

IF YES SPECIFY*

DATE AVAILABLE TO START*

Date

SALARY DESIRED*

LEAST ACCEPTABLE SALARY*

HOW DID YOU HEAR ABOUT PENTO HOMECARE AGENCY PLEASE BE SPECIFIC*

(PLEASE BE SPECIFIC)

HAVE YOU EVER FILED AN APPLICATION OR BEEN EMPLOYED WITH PENTO HOMECARE AGENCY?*

YesNo

IF YES GIVE ENTITY AND DATES

Date

DO YOU HAVE THE LEGAL RIGHT TO BE EMPLOYED IN THE UNITED STATES?*

YesNo

WORK HISTORY

LIST THE NAMES OF ALL EMPLOYERS, GIVING THE MOST RECENT POSITION FIRST. PLEASE GIVE THE MONTH AND YEAR FOR EACH POSITION LISTED.

IN ADDITION, BE SURE TO LIST ALL HEALTH OR HUMAN SERVICE PROVIDERS FOR WHICH YOU HAVE WORKED.

EMPLOYER NAME*

ADDRESS*

PHONE( )*

JOB TITLE*

SUPERVISOR*

REASON FOR LEAVING*

DATES EMPLOYED: FROM MO/YR*

Date

TO MO/YR*

Date

Salary Started*

SALARY ENDED*

DUTIES*

EMPLOYER NAME

ADDRESS

Phone

JOB TITLE

SUPERVISOR

REASON FOR LEAVING

DATES EMPLOYED FROM: MO/YR

Date

TO MO/YR

Date

SALARY STARTED

SALARY ENDED

DUTIES

EMPLOYER NAME

ADDRESS

PHONE

JOB TITLE

SUPERVISOR

REASON FOR LEAVING

DATES EMPLOYED FROM: MO/YR

Date

TO: MO/YR

Date

SALARY STARTED

SALARY ENDED

DUTIES

EMPLOYER NAME

ADDRESS

PHONE

Please enter a valid phone number.

JOB TITLE

SUPERVISOR

REASON FOR LEAVING

DATES EMPLOYED FROM: MO/YR

Date

TO: MO/YR

SALARY STARTED

SALARY ENDED

DUTIES

HAVE YOU SIGNED A RESTRICTIVE COVENANT/NON-COMPETE AGREEMENT OR CONFIDENTIALITY STATEMENT AT A PRIOR JOB?*

YesNo

IF YES PLEASE EXPLAIN

HAVE YOU EVER BEEN DISCIPLINED OR DISCHARGED BY AN EMPLOYER FOR CLIENT ABUSE OR NEGLECT?*

YesNo

IF YES PLEASE EXPLAIN

HAVE YOU EVER BEEN CONVICTED (OR PLEAD GUILTY) OF ANY CRIME (FELONY, MISDEMEANOR, OR SUMMARY OFFENSE) INCLUDING DRIVING WHILE INTOXICATED?*

YesNo

IF YES PLEASE EXPLAIN

(INFORMATION REGARDING CONVICTIONS WILL NOT NECESSARILY DISQUALIFY YOU FOR EMPLOYMENT, BUT WILL BE REVIEWED IN LIGHT OF THE DUTIES AND RESPONSIBLILITIES OF THE POSITION BEING SOUGHT)

DRIVER'S LICENSE NUMBER AND STATE*

DRIVER'S LICENSE NUMBER & STATE* *A VALID LICENSE, ACCEPTABLE DRIVING RECORD, AND PROOF OF INSURANCE ARE REQUIRED FOR ALL POSITIONS.

IS THE DRIVER'S LICENSE VALID?

YesNo

HAVE YOU LIVED IN THE STATE OF PENNSYLVANIA FOR AT LEAST TWO CONSECUTIVE YEARS PRIOR TO THE DATE OF THIS APPLICATION?

YesNo

NAME*

ADDRESS*

YEARS COMPLETED*

1234

GRADUATED*

YesNo

MAJOR

DEGREE

NAME

ADDRESS

YEARS COMPLETED

1234

GRADUATED

YesNo

MAJOR

DEGREE

NAME

ADDRESS

YEARS COMPLETED

1234

GRADUATED

YesNo

MAJOR

DEGREE

LIST ANY PROFESSIONAL LICENSES

LICENSE NUMBER

HAS YOUR PROFESSIONAL LICENSE EVER BEEN SUSPENDED OR REVOKED?

YesNo

IF YES, PLEASE EXPLAIN

RELATED INFORMATION

PLEASE LIST ANY OTHER QUALIFICATIONS PROFESSIONAL ORGANIZATIONS ANDOR VOLUNTEER EXPERIENCES THAT ARE APPLICABLE TO THE POSTION FOR WHICH YOU ARE APPLYING YOU MAY EXCLUDE ANY WHOSE NAME WOULD INDICATE THE RACE RELIGION CREED COLOR NATIONAL ORIGIN OR ANCESTRY OF ITS MEMBERS

NAME

IF YOU WORKED FOR PREVIOUS EMPLOYERS UNDER ANOTHER NAME PLEASE GIVE THAT NAME

ARE YOU CURRENTLY EMPLOYED?*

YesNo

IF YES, MAY WE CONTACT YOUR PRESENT EMPLOYER?*

YesNo

NAME*

ADDRESS*

PHONE*

OCCUPATION*

NAME*

ADDRESS*

PHONE*

OCCUPATION*

NAME*

ADDRESS*

PHONE*

OCCUPATION*

AUTHORIZATION OF RELEASE OF INFORMATION

I hereby give Pento Homecare Agency, and any of its affiliates and divisions, the right to thoroughly investigate my past employment, education, police record, activities, and I release from all liability all persons, companies, and corporations supplying such information. I indemnify Pento Homecare Agency against any liability which might result from conducting such an investigation. I understand that any false answers or statements or implications made by me in this application or other required documents shall be considered sufficient cause for denial of employment or discharge.

Additionally, I understand that nothing contained in this employment application or in the granting of an interview is intended to create an employment contract between Pento Homecare Agency and myself for either employment or for the providing of any benefit. No promises regarding employment have been made to me and I understand that no such promise or guarantee is binding upon Pento Homecare Agency unless made in writing by the Owner / President / Chief Executive Officer. If any employment relationship is established, I understand I have the right to terminate my employment at any time for any reason or no reason at all, with or without prior notice, and that Pento Homecare Agency retains the same right.

Pento Homecare Agency does not discriminate on the basis of race, color, national origin, ancestry, religious creed, handicap, or age as stated in the Pennsylvania Human Relations Act of 1955.

The direct care workers of Pento Homecare Agency are required to complete a minimum of 40 hours of training and a competency evaluation, or a state certification program. Training includes information regarding personal hygiene, safe transfer techniques, infection control, and basic nutrition. They also receive a minimum of 16 hours of supervised practical training before having direct contact with a consumer or verification of prior experience.

Each employee must complete all new hire trainings as required by The Department of Health to meet licensure competency requirements.

Homecare services include: Assistance with self-administration of medications, personal care such as assistance with personal hygiene, dressing, and feeding, homemaking such as assistance with household tasks housekeeping, shopping, meal planning and preparation, and transportation, companionship, respite care such as assistance and support provided to the family; and other non-skilled services.

Pento Homecare Agency provides non-skilled services to individuals in their homes or other independent living environments. We conduct criminal background checks and finger printing when required on all staff. We also conduct Physicals and Tuberculosis screenings for all direct care workers and office staff with direct consumer contact upon hiring and on a yearly basis. We ensure the competency of individuals that provide care by making sure they: Possess a valid nurses license; or demonstrate competency by passing a competency examination developed by the Pennsylvania Homecare Association and approved by The Pennsylvania Department of Health; or have successfully completed at least one of the following: The nurse aide certification and training program sponsored by the Department of Education, a home health aide training program meeting the requirements of 42 C.F.R 484.36, a training program developed by a Pento Homecare Agency, or other entity that meets the requirements, a training program meeting the training standards imposed on Pento Homecare Agency by virtue of their participation as a provider in a Medicaid Waiver or other publicly funded program providing home and community based services, a program approved by the department and published in the Pennsylvania Bulletin or posted on the Department's website. We review direct care competency at least annually, more frequently if warranted, to ensure direct care workers have the proper skills to provide the care required for consumers.

NAME OF APPLICANT PRINT*

DATE*

Date

SIGNATURE OF APPLICANT*

DATE*

Date

CONSUMER RIGHTS

(Defined in the PA Department of Health Regulations Chapter 611.57 Consumer Protections)

(a) Consumer rights. The consumer of home care services provided by a home care agency or through a home care registry shall have the following rights:

(1) To be involved in the service planning process and to receive services with reasonable accommodation of individual needs and preferences, except where the health and safety of the direct care worker is at risk.

(2) To receive at least 10 calendar days advance written notice of the intent of the home care agency or home care registry to terminate services. Less than 10 days advance written notice may be provided in the event the consumer has failed to pay for services, despite notice, and the consumer is more than 14 days in arrears, or if the health and welfare of the direct care worker is at risk.

(b) Prohibitions. No individual as a result of the individual's affiliation with a home care agency or home care registry may assume power of attorney or guardianship over a consumer utilizing the services of that home care agency or home care registry. The home care agency or home care registry may not require a consumer to endorse checks over to the home care agency or home care registry.

(c) Information to be provided. Prior to the commencement of services, the home care agency or home care registry shall provide to the consumer, the consumer's legal representative or responsible family member an information packet containing the following information in a form that is easily read and understood:

(1) A listing of the available home care services that will be provided to the consumer by the direct care worker and the identity of the direct care worker who will provide the services.

(2) The hours when those service will be provided.

(3) Fees and total costs for those services on an hourly or weekly basis.

(4) Who to contact at the department for information about licensure requirements for a home care agency or home care registry and for compliance information about a particular home care agency or registry.

(5) The Department's complaint Hot Line (1-866-826-3644) and the telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA

(6) The hiring and competency requirements applicable to the direct care workers employed by the home care agency or referred by the home care registry.

(7) A disclosure, in a format to be published by the Department in the Pennsylvania Bulletin by February 10, 2010, addressing the employee or independent contractor status of the direct care worker providing services to the consumer, and the resultant respective tax and insurance obligations and other responsibilities of the consumer and the home care agency or home care registry.

NAME OF APPLICANT PRINT*

DATE*

Date

SIGNATURE OF APPLICANT*

DATE*

Date

Your application will be considered for any vacancies for up to 90 days after it is received.

Pento Homecare Agency is an Equal Opportunity Employer

OLDER ADULTS PROTECTIVE SERVICES ACT May 2011

Prohibitive Offenses Contained in Act 169 of 1996 as Amended by Act 13

Following Offenses as Contained in PA Crimes Code (18 Pa. C.S.)

Offense Code Prohibitive Offense Description Type/Grading of Conviction

CC2500 Criminal Homicide Any

CC2502A Murder I Any

CC2502B Murder II Any

CC2502C Murder III Any

CC2503 Voluntary Manslaughter Any

CC2504 Involuntary Manslaughter Any

CC2505 Causing or Aiding Suicide Any

CC2506 Drug Delivery Resulting in Death Any

CC2702 Aggravated Assault Any

CC2901 Kidnapping Any

CC2902 Unlawful Restraint Any

CC3121 Rape Any

CC3122.1 Statutory Sexual Assault Any

CC3123 Involuntary Deviate Sexual Intercourse Any

CC3124.1 Sexual Assault Any

CC3125 Aggravated Indecent Assault Any

CC3126 Indecent Assault Any

CC3127 Indecent Exposure Any

CC3301 Arson and Related Offenses Any

CC3502 Burglary Any

CC3701 Robbery Any

CC3901 Theft

CC3921 Theft By Unlawful Taking

CC3922 Theft By Deception

CC3923 Theft By Extortion

CC3924 Theft By Property Lost Any

CC3925 Receiving Stolen Property ONE (1) Felony

CC3926 Theft of Services or

CC3927 Theft By Failure to Deposit TWO(2)MISDEMEANORS

CC3928 Unauthorized Use of a Motor Vehicle within the 3900

CC3929 Retail Theft series (CC3901-CC3934)

CC3929.1 Library Theft

CC3929.2 Unlawful Possession of Retail or Library Theft Instruments

CC3929.3 Organized Retail Theft

CC3930 Theft of Trade Secrets

CC3931 Theft of Unpublished Dramas or Musicals

CC3932 Theft of Leased Properties

CC3933 Unlawful Use of a Computer

CC3934 Theft From a Motor Vehicle

CC4101 Forgery Any

CC4114 Securing Execution of Documents by Deception Any

CC4302 Incest Any

CC4303 Concealing Death of a Child Any

CC4304 Endangering Welfare of a Child Any

CC4305 Dealing in Infant Children Any

CC4952 Intimidation of Witnesses or Victims Any

CC4953 Retaliation Against Witness or Victim Any

CC5902B Promoting Prostitution Felony

CC5903C Obscene or Other Sexual Materials to Minors Any

CC5903D Obscene or Other Sexual Materials Any

CC6301 Corruption of Minors Any

CC6312 Sexual Abuse of Children Any

Offenses as Contained in PA Controlled Substance, Drug, Device & Cosmetic Act (P.L. 233, No. 64)--PARTIAL LISTING*

Offense Code Prohibitive Offense Description Type/Grading of Conviction

CS13A12 Acquisition of Controlled Substance by Fraud Felony

CS13A14 Delivery by Practitioner 7 Felony

CS13A30 Position with Intent to Deliver Felony

CS13A35 (i),(ii),(iii) Illegal Sale of Non-Controlled Substance Felony

CS13A36 Designer Drugs Felony

CS13Axx* ANY OTHER FELONY DRUG CONVICTION APPEARING ON PA RAP SHEET

Effective February 4, 2004, facilities will not be sanctioned for hiring or continuing to employee individuals who demonstrate rehabilitation by evidence for a minimum five-year aggregate work history in care-dependent services, without incident, from either the date of conviction or release from incarceration, whichever is later. Applicants are responsible for providing official verification of such dates. Care-dependent services include healthcare, eldercare, childcare, mental health, mental retardation, or care of the disabled. Facilities must reasonably investigate the character of an individual with a previously disqualifying criminal offense by means of interviews, references and evidence of work history. Facilities that hire such as individual are required to obtain specific employer-provided documentation of that individual's personnel file. (This provision applies to the Older Adults Protective Services Act (OAPSA) only

I understand as a provisionally hired employee I must work within the eyesight of a regular, full time employee at all times. My provisional period is 30days.

I understand that I must be dismissed from employment if I have been convicted of any of the crimes listed above within the past five years.

I hereby swear / affirm that the information as set forth above is true and correct. I understand that the penalty for false swearing is a misdemeanor of the third degree pursuant to Section 4903(b) of the Crimes Code.

FOR ADDITIONAL EMPLOYEE STATEMENT, IF APPLICABLE.

Employee Name (Print)*

Date*

Employee Signature*

Date*

Witness Name (Print)

Date

Witness Signature

Date

(DPW, CY&F) June 8, 2005, (Dept of Aging) December 23, 2003 and (PA Dept. of Aging Interim Guidance) February 6, 2004, Pento Homecare Agency Revision September 2013.

PENTO HOMECARE AGENCY HOME HEALTH AIDE AGREEMENT OF HOURS TO WORK

If offered a position as a direct care professional, I have agree to be available for scheduling of cases, the following days and times. I understand that I must work at least 8 hours a week to maintain my status at Pento Homecare Agency as a Direct Care Professional.

I understand that by committing to and signing this agreement, I will be given a schedule that is suitable to what I have indicated below as my starting availability as a new Home Health Aide with Pento Homecare Agency.

I also understand that if I refuse to accept a schedule that I have stated I am available for, I will risk not being assigned any cases / hours to work for an unspecified period of time as it may also lead to being terminated as a Pento Homecare Agency employee if there are no available hours.

If in the future, as a Home Health Aide, my schedule availability were to change after starting (i.e., for reasons such as school scheduling, another job, etc. ) I will work with my direct supervisor on my schedule. However, I would continue to remain committed to work the schedule that I would be given initially until such changes would be able to be made.

Number of hours per week maximum that I am willing to work*

Signature of Interviewee*

DISCLAIMER FOR PENTO HOMECARE AGENCY JOB DESCRIPTION

The attached job description is to provide you with information about the position you are applying/ interviewing for. The attachment of this job description in no way implies an offer of employment.

Please sign the attached job description with your application.

Employee Name*

1. Job Activities

Activities may include but are not limited to

- Basic housekeeping and home management necessary to ensure safe and sanitary

- Shopping assistance with or without the consumer.

- Laundry including washing, drying, putting away.

- Transportation of a consumer to complete chores or keep appointments when alternative inappropriate or unavailable

- Meal planning, preparation, clean-up

- Escort to medical appointments

- Assisting consumer with ambulation and transfers

- Assisting with routine bodily functions, including eating, feeding, toileting, bathing, dressing, grooming

- Providing health maintenance activities including activities such as skin care, mouth care,

- Companion-type services including, but not limited to, assistance with transportation, letter escorting

- Supervision of consumers for clients and safety General Responsibilities:

- Become familiar with policies and procedures that are associated with Pento Homecare Agency.

- Establish an effective working relationship with co-workers, management, families, consumers, and payor sources.

- Attend staff meetings, and mandatory in-service trainings as instructed

- Carry out all duties in a responsible, professional, and ethical manner upholding the mission of Pento Homecare Agency.

-Perform other duties and job activities as are assigned

EDUCATION:

__ Less than high school diploma

(X) High School diploma or equivalent

__ High School plus some college, business or technical

__ 2-Year / Associate Degree

__ 4-Year / Bachelor Degree

__ Graduate / Master Degree

__ Post Graduate Degree

__ License / Certification

EXPERIENCE: Minimal Required

__ None

(X) Less than one year

__ 1-3 years Direct Care Services exp.

__ 3-5 years

__ More than 5 years

__ Other (explain):

SKILLS:

(X) Organizational

(X) Verbal

(X) Interpersonal

(X) Customer Relations

Mathematical

Grammar / Spelling

(X) Read / Comprehend written instructions

Computer: (Specify)

__ Transcription

(Specify)

Other: (Specify)

(X) Problem Solving

Supervision

Public speaking

Analytical

(X) Teamwork

(X) Follow verbal instructions

MENTAL AND EMOTIONAL REOUIREMENTS:

(X) Manage stress appropriately

(X) Make decisions under pressure

(X) Manage anger/ fear/hostility/ violence of others appropriately

(X) Handel Multiple priorities

(X) Work Alone

__ Work in areas that are confined and/ or crowded

DEGREE OF SUPERVISON REQUIRED

CLOSE SUPERVISION: Individual does not use own initiative, but is instructed by supervisor as to the solution and selection of proper procedures to follow.

MODERATE SUPERVISION: Involves guidance and direction by immediate supervisor.

LIMITED SUPERVISOR: Individual proceeds on his/her own initiative, in compliance with policies, practices and procedures prescribed by immediate supervisor.

EQUIPMENT USED (Please check all that apply):

__ Photocopy Machine

__ Fax Machine

__ Postage Meter/ Scale

__ Shredder

__ Typewriter

(X) Telephone

(X) Answering Mach./Voice Mail

__ Pager/ Beeper

__ Loudspeaker / Paging System

(X) VCR

(X) Television

(X) Washer / Dryer

(X) Microwave

(X) Gas / Electric Oven

__ Transcription / Dictation Equip.

__ Calculator

__ Computer - IBM Compatible Software

__ Other

WORKING CONDITIONS (Please check one of the following):

(X) INSIDE: Spends approximately 75% or more of the time inside. Inside work has good ventilation, comfortable, temperature.

__ OUTSIDE: Spends approximately 75% of time outside.

__ BOTH: The activities occur inside or outside in approximately equal amounts.

HAZARDS (Please check all that apply to the position):

__ Exposure to toxic/caustic/chemical detergents

__ Exposure to extreme conditions, hot/cold

(X) Exposure to dust/fumes/gasses

__ Exposure to mechanical parts

__ Exposure to potential electric shock

__ Exposure to x-ray/electromagnetic energy

(X) Exposure to cigarette smoke

(X) Exposure to cellular telephones

__ Exposure to high pitched noises

(X) Exposure to communicable diseases

(X) Exposure to blood and/ or body fluids

__ Exposure to excessive sunlight or work outdoors

__ Unprotected heights

__ CRT (computer) monitor

(X) Exposure to strong odors

__ Operating heavy equipment

__ Others (specify)

PHYSICAL REQUIREMENTS / ACTIVITY:

__ SEDENTARY WORK: Prolonged periods of sitting and exert 10lbs of force occasionally. LIGHT WORK: Exert up to 20 lbs of force occasionally, and / or up to 10lbs of force frequently.

(X) MEDIUM WORK: Exert up to 50lbs occasionally, and/ or up to 20lbs frequently, and/ or up to continuously.

__ HEAVY WORK: Exert up to 100lbs occasionally, and/or 50 lbs frequently, and/ or over 20 lbs

__ VERY HEAVY WORK: Exert over 100 lbs force occasionally, and/ or over 50 lbs frequently, and /or over 20lbs continuously.

1-Not at all(0%) 2-Occasionally(1-33%)

3-Frequently(34-66%) 4-Continuously(67-100%)

1	2	3	4		1	2	3	4
	X			Climbing			X		Lifting
	X			Balancing			X		Fingering
		X		Stooping			X		Grasping
		X		Kneeling			X		Feeling
		X		Crouching			X		Talking
	X			Crawling			X		Hearing
			X	Reaching		X			Repetitive Motions
			X	Standing		X			Reading
			X	Walking		X			Writing
		X		Pushing		X			Driving
		X		Pulling		X			Sitting
			X	Seeing		X			Distiguishing Colors

CLIMBING	Ascending or descending ladders, stairs, scaffolding, ramps, poles, and the like. Using feet and legs, and/or hands and arms. Body agility is emphasized. This factor is important if the amount and kind of climbing required exceeds that required for ordinary locomotion.
BALANCING	Maintaining body equilibrium to prevent falling, when walking, standing, or crouching on narrow, slippery or erratically moving surfaces. This factor is important if the amount and kind of balancing exceeds that needed for ordinary locomotion and maintenance of body equilibrium.
STOOPING	Bending body downward and forward by bending spine at the waist. This factor is important if it occurs to be a considerable degree and requires full use of the lower extremities and back muscles.
KNEELING	Bending legs at knee to come to rest on knee or knees.
CROUCHING	Bending the body downward and forward by bending leg at spine.
CRAWLING	Moving about on hands and knees or hands and feet.
REACHING	Extending hand(s) and arm(s) in any direction.
STANDING	Particularly for sustained periods of time.
WALKING	Moving about on foot to accomplish tasks, particularly for long distances.
PUSHING	Using upper extremities to exert force in order to draw, drag, haul, or tug objects in a sustained motion.
PULLING	Using upper extremities to exert force in order to draw, drag, haul, or tug objects in a sustained motion.
LIFTING	Raising objects from a lower to higher position or moving objects horizontally from position to position. This factor is important if it occurs to a considerable degree and requires the substantial use of the upper extremities and back muscles.
FINGERING	Picking, pinching, typing, or otherwise working, primarily with fingers rather than the whole hand or arm as in handling.
GRASPING	Applying pressure to an object with fingers and palm.
FEELING	Perceiving attributes of objectives, such as shape, size, temperature, or texture by touching with skin, particularly that of the fingertips.
TALKING	Expressing or exchanging ideas by means of the spoken word. Those activities in which they must convey detailed or important spoken instructions to other workers accurately, loudly, of quickly.
HEARING	Perceiving the nature of sounds with no less than a 40 dB loss at 500 Hz, 1,000 Hz and 2,000 Hz with or without correction. Ability to receive detailed information through oral communication, and make fine discrimination in sound, such as when making adjustments on machined parts.
READING	Looking at carefully so as to understand the meaning of something written, printed, etc.
WRITING	Expressing or communicating in written form; giving a written account of.
DRIVING	Operating a vehicle; may include transporting others.
SITTING	Being seated with the body supported by the buttocks or thighs.
SEEING	Perceiving with the eyes; looking at.
DISTINGUSHED COLORS	Having non-defective color perception
REPETITIVE MOTIONS	Substantial movements (motions) Including, but not limited to, the wrists, hands and/or fingers.

I, First Name Last Name acknowledge that I have read, and received the attached job description for the position of Position* , which I am interviewing for today. I can complete the essential job functions with or without reasonable accommodation(s

Applicants Signature*

Date*

Date

EQUAL EMPLOYMENT POLICY

Pento Homecare Agency does not discriminate on the basis of race, color, national origin, ancestry, religious creed, handicap, or age as stated in the Pennsylvania Human Relations Act of 1955.

EMPLOYMENT APPLICATION

EDUCATION

HIGH SCHOOL

UNDERGRADUATE COLLEGE

GRADUATE / PROFESSIONAL

PROFESSIONAL LICENSE AND/OR CERTIFICATIONS

REFERENCES

GIVE THREE WORK-RELATED - REFERENCES:

CONSUMER RIGHTS

JOB DESCRIPTION

POSITION SUMMARY:

EVALUATE THE REQUIREMENTS AND ACTIVITY PERCENTAGE IN TIME FOR THIS POSITION BASED ON THE FOLLOWING:

DEFINITION OF PHYSICAL ACTIVITY

Pento Homecare Agency