Employment Application

Employment Application

Employee Information
Position Applied for:*
Date*

MonthDayYear
Date
Name*

First NameMiddle NameLast Name
Maiden or previous names

First NameLast Name
Date of Birth*

MonthDayYear
Date
Social Security Number *
Social Security Number
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Main Telephone Number*
Email*
example@example.com
How did you hear about us?*
Referred by:
Are you eligible to work in the US? Can you provide the required proof of your eligibility?*

YesNo
Have you ever filed an application with us before?*

YesNo
Are you currently employed? *

YesNo
May we contact your current employer?*

YesNo
Are you prevented from lawfully becoming employed in this country because of a Visa or Immigration status? (Proof of citizenship or immigration status will be required upon employment) *

YesNo
Date Available to start work:*

MonthDayYear
Date
Type of work desired*

Full-timePart-timeSubstitute/ As needed
Preferred shifts*

1st (anytime b/t 7a-4p)2nd (anytime b/t 1p-11p)3rd (anytime b/t 10p-9a)Any/ no preference

Please list your availability*

	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
From
To

Please indicate any shifts/ times that you are unable to work*

Driver's License Requirements

Driver's License Requirements*

	Yes	No
Do you have a valid PA driver's license?
Do you have reliable transportation or other means to get to/ from work?
Do you have a properly insured vehicle?
Have you had any moving violations in the past 3 years? If yes, list below.

Please list any violation here:
Please enter your driver's license number: *
Expiration Date

MonthDayYear
Date
Driver's license state*

Physical Requirements
For positions that require these physical requirements, you must be able to operate equipment (e.g. wheel chairs, hand trucks). Must be able to exert up to 75 lbs of force occasionally and/or frequently to lift, carry, push, pull or otherwise move objects. Physical demands are in excess of sedentary work; position requires walking, standing, reaching, lifting, pushing, stooping, etc. Will lift no more than 40 lbs independently. Must be able to lift and/or carry weights of up to 175 lbs with assistance.

Are you able to meet these requirements?
Choose one:*

YesNo

Clearances
All positions at Tutelage Residential Services require an Act 34 State Police Criminal History Clearance or FBI Act 73 Criminal Clearance.

Cleareances*

	Yes	No
Have you ever been convicted of any crime? If yes, explain below.
Have you lived out of the state within the last 2 years?
In the event Tutelage Residential Services provides services to anyone under the age of 18, have you ever been convicted of any child abuse related crimes? If yes, explain below.

If you have been convicted of any crime, please give dates and explain
If you have been convicted of any child abuse related crimes, please give dates and explain

References
Please list three professional references that can provide an employment related reference. By providing this information you agree that we can contact those listed. Do not include personal/ character references such as relative or friends.
Professional Reference #1*

First NameLast Name
Phone Number*
Title*
Their professional relationship to you*
Professional Reference #2*

First NameLast Name
Phone Number*
Title*
Their professional relationship to you*
Professional Reference #3*

First NameLast Name
Title*
Phone Number*
Their professional relationship to you*

Education & Qualifications

Education*

	Name/ City	Course of Study	# of Years Completed	Type of Diploma/ Degree
High School
Undergraduate
Graduate/ Professional
Military Service
Other (Specify)

Other relevant job qualifications/ trainings:
State any additional information you feel may be helpful to us in considering your application:

Employment History
Start with your most recent employer. Include your three most recent jobs held regardless of length of service. Include any job-related military experience assignments and other volunteer activities. You may exclude organizations which include race, color, religion, gender, national origin, disabilities or other protected status.
Employer #1*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Job Title*
Job Duties
Begin Date*

MonthDayYear
Date
End Date*

MonthDayYear
Date
Are you still employed here?*
Supervisor Name*

First NameLast Name
Contact Phone Number*
Reason for leaving*
Employer #2*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Job Title*
Job Duties
Begin Date*

MonthDayYear
Date
End Date*

MonthDayYear
Date
Supervisor Name*

First NameLast Name
Contact Phone Number*
Reason for leaving*
Employer #3*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Job Title*
Job Duties
Begin Date*

MonthDayYear
Date
End Date*

MonthDayYear
Date
Supervisor Name*

First NameLast Name
Contact Phone Number*
Reason for leaving*
Please explain any gaps in employment:

Follow up questions:*

	Yes	No
If you are selected for an interview, do you need an interpreter?
If you are offered a position will you require an interpreter?
Are you capable of performing in a reasonable manner, with or without reasonable accommodation, the essential functions involved in the job for which you have applied?

Resume submission is required. Please upload a copy of your resume*

Browse Files

Cancelof

Employee Certification
Applicant’s statement:

·         I certify that answers given herein are true and complete.

·         I certify that I have read and understand the "Tutelage Residential Services Voluntary Invitation for Applicant Self-Identification" (above).

·         I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision, including contacting previous employers. I further authorize Tutelage Residential Services to obtain from a consumer reporting agency a report on my driving record, Act 33/34 clearances, and/or FBI (Act 73) check.

·         This application for employment shall be considered active for a period of time not to exceed six (6) months. I understand that I will be considered for positions for which I may qualify, but my application does not guarantee an interview will result.

·         I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an "at will" nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this "at will" employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization.

·         In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in immediate termination. I understand, also, that I am required to abide by all rules and regulations of the employer.

By choosing to submit the form, I hereby guarantee the correctness of all the statements and information provided above.

I understand that the making of false statements will be sufficient cause for denying me consideration for employment or termination from employment.
By typing your name, you are agreeing to the above, should you be selected for an interview, you will be asked to physically sign your application.
Do you agree?*

YesNo
Name*

First NameLast Name
Date*

MonthDayYear
Date

Voluntary Information
Applicant Self-Identification form. This information is strictly voluntary, you do not have to answer. If you chose not answer, please scroll down and click submit:

Tutelage Residential Services commitment to equal opportunity, nondiscrimination in employment. We are committed to the legal responsibilities to ensure equal employment opportunity and compliance regadrless of protected class. This information assists with reporting and said compliance and accountability.

This information:

· is voluntary

· is gathered for statistical purposes only

· is kept confidential, separate from application materials

· will not be used in any way to evaluate your qualifications for employment
Gender
Ethnicity
Are you multiracial?
Which race(s) are you. Check all that apply
If other, please specify:

Employee Authorizations
Authorization to Release Employment Information

The person completing this application has applied for a position with Tutelage Residential Services, LLC.

You hereby authorize Tutelage Residential Services, LLC and its duly authorized representatives to obtain information from personal references such as co-workers and friends and professional references from employers, educational institutions and volunteer work that you have participated in to be considered for employment with their agency.

You further authorize any person, educational institution, or company that you have listed as a reference on my employment application to disclose in good faith any information they may have regarding my qualifications and fitness for employment. This personal and employment information, both oral and written, may include material contained in my personnel file and evaluative statements and judgments from my former supervisors. This employment information includes for example, academic, salary, achievement, performance, attendance, personal history, disciplinary records, and employment information. You hereby authorize release any individual providing reference or employment information under this authorization including record custodians from all liability for damages of whatever kind or nature that may at any time result to me on account of compliance, or any attempts to comply, with this authorization.

By typing your name below, you are agreeing and authorizing this request.
Name*

First NameLast Name
Date*

MonthDayYear
Date

Authorization to Consent to Criminal Background Check

The person completing this application has applied for a position with Tutelage Residential Services, LLC.

You understand that a criminal history check will be ran on the Pennsylvania Criminal History (PATCH) website by Tutelage Residential Services AND/ OR fingerprinted by the FBI upon initial employment/ application and, per agency policy, at renewal every two (2) years.

As a condition of employment, you acknowledge that was asked at the time of phone screening and interview about your criminal history. You understand that you must have/ had an acceptable criminal history with no disqualifying items.

You certify and attest that there are no criminal charges, misdemeanors or felonies that would preclude you from employment. You understand that you must disclose all charges and pending charges at prior to employment AND if hired during employment reporting within five (5) days. You acknowledged that you were informed that one of the contingencies of employment is a return of a satisfactory criminal history which does not preclude employment.

You understand that you are a provisional employee and cannot work alone with any participants until your criminal history returns either at employment or at renewal if currently employed and shows a satisfactory and nonqualifying result. You also understand that you will be immediately terminated for the following: (1) If your criminal history is returned with any unsatisfactory or disqualifying items upon initial employment/ application; (2) You did not disclose any such items at application/ offer of employment and/ or at signing this form; (3) if items any such items were returned during two (2) year recertification; (4) You did not disclose any such items during my employment within five (5) days to your supervisor and Personnel department; (5) and any other such violation regarding this policy that warrants special circumstances concerning any of the above where specific action may need to be taken.

By typing your name below, you are agreeing and authorizing this request.

You are also agreeing to list any violations below.
Name*

First NameLast Name
Date*

MonthDayYear
Date
Should be Empty: