Employment Application Step 1 of 4 25% Please Enter Today's Date* Applicant Name* First Last Address* Street Address Address Line 2 City State / Province*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Telephone Number*POSITION(S) APPLIED FOR OR TYPE OF WORK DESIRED* CNA LPN RN Wait Staff/Server Utility Housekeeper Lifeguard Security Officer Administrative Other *Type of Employment Desired* Full Time Part Time Pool/Per Diem Have you ever previously employed by The Philadelphia Protestant Home?*YesNoDo any of your relatives work here?YesNoAre you under the age of 18?*YesNoIf you answered yes to the previous question, are you able to provide required proof of your eligibility to work?YesNoAre you a U.S. citizen or legally authorized to work in the United States?*YesNoTo your knowledge are you able to perform the duties of the job for which you are applying?YesNoHave you ever been dismissed from employment due to abuse of a patient, client or resident?*YesNoHow were you referred to us? Website Newspaper Ad School PPh Employee Community Referral Agency Other List Your Previous Employers Beginning With Your Most Recent. If you have not been employed please indicate "N/A".**What was your most recent position?*Street AddressCityStateZip CodeTelephone NumberDate Employed From Date Employed To Direct Supervisor and Their TitleJob SummaryReason For LeavingCheck Here To Add An Additional Employer (2) Add An Additional Employer Street AddressCityStateZip CodeTelephone NumberDate Employed From Date Employed To Direct Supervisor and Their TitleJob SummaryReason For LeavingCheck Here To Add An Additional Employer (3) Add An Additional Employer Street AddressCityZip CodeStateTelephone NumberDate Employed From Date Employed To Direct Supervisor and Their titleJob SummaryReason For Leaving Do you possess a Professional Registration or License?*YesNoEnter your License/Registration number.What is the date your License/Registration expires? Other Skills And QualificationsEducational HistoryList school name and location, years completed, course of study, and any degrees earned:High School Name*DegreeCollege/University NameDegreeTechnical/Vocational School NameDegree/Certificate/LicensureOtherReferencesList the names, telephone numbers and years known of three references (do not include relatives or employers).Reference 1 Name*Reference 1 Phone*Reference 1 AddressReference 2 Name*Reference 2 Phone*Reference 2 AddressReference 3 NameReference 3 PhoneReference 3 Address APPLICANT CERTIFICATION AND AGREEMENTI certify that the information I have provided to the foregoing questions is true and correct, and no attempt has been made to conceal information. I authorize my former employers, schools and personal references to provide any information they may have regarding me, whether or not it is on their records. I fully agree that if I have ever been dismissed from employment or if it has been proven that I have ever absued a patient, client or resident, I am not eligible for employment at The Philadelphia Protestant Home. I hereby release them and their company from all liability for divulging same. I understand that if any information given by me in this application, is found to be false or misleading, I will be subject to dismissal at anytime during the prior of my employment. I also understand that a criminal background check will be conducted. If employment is obtained under this application, I will comply with all the rules and regulations of The Philadelphia Protestant Home. I also understand that if I am employed, I will be required to provide satisfactory proof of identity and legal work authorization within three days of being hired. Failure to submit such proof within the required time shall result in immediate termination of employment. I represent and warrant that I have read and fully understand the foregoing, and that I seem employment under these conditions. I understand that I will be required to undergo a pre-employment physical and drug screening as a condition of my employment. AND I understand that if I am employed by PPh, my employment will be for no set period of time and may be terminated by PPh at any time with or without cause. I further understand that nothing shall change the at-will status of my employment other than a written agreement signed by me and The Philadelphia Protestant Home, expressly changing the employment-at-will status. I also understand that, if employed, I will be required to abide by all of the policies, rules and regulations of the organization. Do you agree to the above terms?* Check this box to agree to the above terms. Applicant Signature (Please type in your name)*PhoneThis field is for validation purposes and should be left unchanged. 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