George Junior Republic

233 George Junior Road
P.O. Box 1058
Grove City, PA 16127-5058

Telephone: 724-458-9330 • Fax: 724-458-0912

APPLICATION FOR EMPLOYMENT

This facility is an equal opportunity employer. We recruit, hire, train, and promote without discrimination due to race, color, religion, sex, national origin, ancestry, marital or veteran status, age, or disability. No question on this application is asked for the purpose of limiting or excluding any applicant’s consideration for employment due to race, color, religion, sex, national origin, ancestry, marital or veteran status, age, or disability.

If handwritten, please legibly print all required information.

Date Completed /

LAST NAME / FIRST NAME / MIDDLE INITIAL
ADDRESS (number and street)
CITY / TOWNSHIP / STATE ZIP CODE
()- cell home / ()- / - -
PHONE NUMBER / ALTERNATE PHONE NUMBER / SOCIAL SECURITY NUMBER
Have you been previously employed here? Yes No If yes, when?
If you are under 18 years of age, can you provide required proof of your eligibility to work? Yes No
Are you currently on “lay-off” status and subject to recall? Yes No
Referral Source
ADVERTISEMENT
EMPLOYMENT AGENCY / FRIEND
RELATIVE / WALK-IN
OTHER / Name of Source (if applicable)
CURRENT VALID DRIVER’S LICENSE / Has your driver’s license ever been suspended?
Yes No
Number / State
If “Yes”, give details.
Month / Day / Year
EXPIRATION DATE
POSITION OR TYPE OF WORK DESIRED / SALARY REQUIREMENT
EMPLOYMENT DESIRED
Full-Time / Summer / Temporary
Part-Time(specify days & hours per week)
DATE AVAILABLE FOR EMPLOYMENT
ARE YOU WILLING TO RELOCATE? YES NO

WE ARE AN EQUAL OPPORTUNITY EMPLOYER

EMPLOYMENT DATA: List previous/current employment record beginning with the most recent employer (including military service).

FROM (MONTH/YEAR)
/ / NAME AND ADDRESS OF EMPLOYER
NAME / IMMEDIATE SUPERVISOR
NAME
TO (MONTH/YEAR)
/ / ADDRESS / TITLE
CITY / STATE / TELEPHONE NUMBER ()-
LAST SALARY
$ / ZIP CODE / TELEPHONE NUMBER ()- / IF PRESENT EMPLOYER, MAY WE CONTACT? YES NO
POSITION TITLE: / STATUS: FULL-TIME PART-TIME TEMPORARY
DESCRIBE YOUR PRINCIPAL DUTIES OR RESPONSIBILITIES:
REASON FOR LEAVING:
FROM (MONTH/YEAR)
/ / NAME AND ADDRESS OF EMPLOYER
NAME / IMMEDIATE SUPERVISOR
NAME
TO (MONTH/YEAR)
/ / ADDRESS / TITLE
CITY / STATE / TELEPHONE NUMBER ()-
LAST SALARY
$ / ZIP CODE / TELEPHONE NUMBER ()- / IF PRESENT EMPLOYER, MAY WE CONTACT? YES NO
POSITION TITLE: / STATUS: FULL-TIME PART-TIME TEMPORARY
DESCRIBE YOUR PRINCIPAL DUTIES OR RESPONSIBILITIES:
REASON FOR LEAVING:
FROM (MONTH/YEAR)
/ / NAME AND ADDRESS OF EMPLOYER
NAME / IMMEDIATE SUPERVISOR
NAME
TO (MONTH/YEAR)
/ / ADDRESS / TITLE
CITY / STATE / TELEPHONE NUMBER ()-
LAST SALARY
$ / ZIP CODE / TELEPHONE NUMBER ()- / IF PRESENT EMPLOYER, MAY WE CONTACT? YES NO
POSITION TITLE: / STATUS: FULL-TIME PART-TIME TEMPORARY
DESCRIBE YOUR PRINCIPAL DUTIES OR RESPONSIBILITIES:
REASON FOR LEAVING:
FROM (MONTH/YEAR)
/ / NAME AND ADDRESS OF EMPLOYER
NAME / IMMEDIATE SUPERVISOR
NAME
TO (MONTH/YEAR)
/ / ADDRESS / TITLE
CITY / STATE / TELEPHONE NUMBER ()-
LAST SALARY
$ / ZIP CODE / TELEPHONE NUMBER ()- / IF PRESENT EMPLOYER, MAY WE CONTACT? YES NO
POSITION TITLE: / STATUS: FULL-TIME PART-TIME TEMPORARY
DESCRIBE YOUR PRINCIPAL DUTIES OR RESPONSIBILITIES:
REASON FOR LEAVING:
FROM / TO / EMPLOYER NAME / JOB TITLE / SUPERVISOR’S NAME
/ / /
/ / /
/ / /
/ / /
/ / /

HIGH SCHOOL (NAME, CITY, STATE) / GRADUATED
YesNo / GED
Yes
COLLEGE OR OTHER EDUCATIONAL INSTITUTIONS / LOCATION (CITY / STATE) / YEAR ATTENDED / DID YOU GRADUATE? / DIPLOMA, DEGREE OR CERTIFICATE / CREDIT HOURS EARNED / MAJOR / MINOR
Y N
Y N
Y N
Y N
PERSONAL COMPUTER WORD PROCESSING SPREADSHEET
DATA ENTRY STROKES PER HOUR TYPING WORDS PER MINUTE
SOFTWARE USED:
MACHINERY OPERATED:
LIST SPECIAL SKILLS (MAINTENANCE, FOREIGN LANGUAGE, ETC.):
1. / LIST ANY MEMBERSHIP(S) IN PROFESSIONAL, JOB-RELATED ORGANIZATIONS:
2. / LIST PROFESSIONAL, TECHNICAL, OCCUPATIONAL LICENSES, OR CERTIFICATES.
3. / LIST AWARDS, COMMENDATIONS, OR OTHER RECOGNITION RECEIVED FOR OUTSTANDING ACHIEVEMENT IN SCHOOL,
MILITARY SERVICE, YOUR WORK.
4. / PROVIDE ANY FURTHER INFORMATION SUCH AS VOLUNTEER EXPERIENCE THAT MAY BE HELPFUL IN CONSIDERING YOUR
QUALIFICATIONS.
LIST THREE RESPONSIBLE ADULTS WHO HAVE KNOWN YOU FOR AT LEAST THREE YEARS. DO NOT INCLUDE RELATIVES,
FORMER EMPLOYERS, OR PRESENT EMPLOYERS.
1.
NAME / OCCUPATION
ADDRESS / TELEPHONE NUMBER
2.
NAME / OCCUPATION
ADDRESS / TELEPHONE NUMBER
3.
NAME / OCCUPATION
ADDRESS / TELEPHONE NUMBER

PLEASE READ CAREFULLY BEFORE SIGNING

I certify that the information contained in this application is correct to the best of my knowledge and understand that any falsification, misrepresentation, or omission on this application is grounds for refusal to hire, or if hired, dismissal. I authorize any of the persons or organizations referenced in this application to give George Junior Republic any and all information concerning my previous employment, education, or any other information they might have with regard to any of the subjects covered by this application. I release all such parties and George Junior Republic from all liability for any damage that may result from furnishing such information. I authorize George Junior Republic to request and receive such information.

If employed, I understand that I will be an employee “at will” and either George Junior Republic or I may terminate my employment relationship at any time with or without notice for any reason not in violation of any state or federal law.

The Age Discrimination in Employment Act prohibits discrimination on the basis of age with respect to individuals who are at least 40 years of age.

Employment is contingent upon Act 33 Clearance and Pennsylvania Child Abuse Clearance and / or FBI Background Check approval. I hereby agree to complete all necessary forms in regard to the aforementioned clearances.

George Junior Republic has a zero tolerance for abuse policy and all staff are mandated reporters.

A post offer, pre-employment physical is required. I hereby agree to complete such an exam if offered employment.

SIGNATURE / DATE

APPLICANT’S CERTIFICATIOn and agreement

PRE-EMPLOYMENT DRUG TESTING POLICY

I understand and agree that I will be required to take a Drug Detection Test as a condition of hiring or continued employment. I agree to consent to take such test at such time as designated by George Junior Republic, and to release George Junior Republic, its directors, officers, agents, or employees from any claim arising in connection with the use of such test.

YESNO

SIGNATURE / DATE