Employment Application

Fill out the following application for employment below to submit your information to us.

Click here if you need a printable version.

Application For Employment
IF YOU REQUIRE ANY ACCOMODATION(S) DURING ANY OR ALL PARTS OF THE APPLICATION/PRE-EMPLOYMENT PROCESS, PLEASE INFORM HUMAN RESOURCES SO THAT ASSISTANCE MAY BE PROVIDED TO YOU.

WE WILL MAINTAIN YOUR APPLICATION ON FILE FOR ONE YEAR FOR REFERRAL PURPOSES.

Please read all instructions carefully and complete all sections of the application. We will use the information you provide below to determine appropriate job placement with St. Joseph's Center. Even after hire, the information you provide here and during the pre-employment process will be relied on by St. Joseph's Center as being true, complete and accurate for various purposes. Likewise, if you include your resume, make sure that you have provided all requested information, including your employment, education, salary history and references and that your resume is true, complete and accurate.

St Joseph's Center is an Equal Opportunity Employer. Federal and State laws prohibit discrimination in employment practices because of race, color, ancestry, religious creed, age, sex, national origin or disability. No question on this application is asked for the purpose of limiting or excluding any applicant considered for employment because of his/her race, color, ancestry, religious creed, age, sex, national origin, disability or other lawfully protected trait.
General Information
Note: Bold items are required.
Last Name
First Name
Middle Name
Street
City
State
Zip Code
Home Phone
Cell Phone
Social Security
Email Address
Position(s) Desired
Pay Expected
Desired Location

How did you learn about this position?

What type of employment do you want?
Date Available

Yes No Are you willing to work weekends?
Yes No Are you willing to work holidays?
Yes No Are you legally authorized to work in the United States
Yes No Are you 18 years of age or older? If no, do you have working papers? Yes No
Yes No Have you ever been employed by St. Joseph's Center?
If yes, date:
position:
Yes No Have you ever been known by a different name?
List name(s):
Yes No Can you perform the essential functions of the job for which
you are applying with or without reasonable accommodations?
Yes No Do you have any employment commitments with any other employer, including any form of self-employment or contract work, which you expect even if you are hired by St. Joseph's Center.
If yes, how many jobs do you currently hold?
Education
 Name & AddressCourse of StudyYears CompletedGraduate?List Degree
High School Yes No
College Yes No
Graduate School Yes No
Other Trade, Business Yes No

Special Skills (review job description on file in the Human Resources Office)
Typing WPM Medical Terminology Personal Computer
Computer Programs
Are there any other special experiences or skills you feel would especially qualify you for the position?
Military (complete this section if you served in the US Armed Forces)
Branch Of Service
Period of Active Duty (Month/Year)
From To
Rank of Discharge
Date of Final Discharge
Describe your duties and any special training which may be related to the position for which you are applying:
Professional License And Certification
TypeOrganizationState IssuedNumberExpiration

References:List Four (4) Supervisors, Instructors, or other professional references. Do not list relatives.
NameAddressTelephone

Employment History (Start with present or most recent employer)
Company Name
Telephone
Address
Employed (Month/Year)
From To
Name/Title of Immediate Supervisor
Rate Of Pay
Start Last
Job Title
Reason For Leaving
Job Duties/Responsibilities
May we contact?
Yes No
Company Name
Telephone
Address
Employed (Month/Year)
From To
Name/Title of Immediate Supervisor
Rate Of Pay
Start Last
Job Title
Reason For Leaving
Job Duties/Responsibilities
May we contact?
Yes No
Company Name
Telephone
Address
Employed (Month/Year)
From To
Name/Title of Immediate Supervisor
Rate Of Pay
Start Last
Job Title
Reason For Leaving
Job Duties/Responsibilities
May we contact?
Yes No
Company Name
Telephone
Address
Employed (Month/Year)
From To
Name/Title of Immediate Supervisor
Rate Of Pay
Start Last
Job Title
Reason For Leaving
Job Duties/Responsibilities
May we contact?
Yes No

Digital Signature and Acceptance
All job offers for positions requiring the operation of a St. Joseph's Center Company vehicle will be contingent upon confirmation of a valid driver's license and driver's background check through the PA Department of Motor Vehicles.
Please answer the questions below:

Yes No Do you possess a valid PA driver's license?
Yes No Do you presently have auto insurance?

I understand that any offer of employment by St. Joseph's Center is contingent upon screening of my work/school/criminal record and personal references. Criminal records will be verified by the State Police or FBI and the Department of Public Welfare's Childline.

Yes No Have you been a resident of PA for the past two consecutive years?
Yes No Have you ever been convicted in any state of the United States of a felony or a misdemeanor, or are there any criminal charges pending against you anywhere? An affirmative answer will not automatically disqualify you from employment.
If yes:Date(s):
Offense(s):
Disposition(s):

I verify that this information is true, and that I have not been convicted of any crime that would disqualify me from the position(s) for which I am applying. I hereby authorize St. Joseph's Center to request, obtain and examine any and all records that may relate to my arrest, conviction and/or imprisonment at any time prior to this date for any felony or misdemeanor and I expressly release and hold harmless any party providing the aforementioned criminal information requested by St. Joseph's Center.
I understand that in accepting this application, St. Joseph's Center is in no way obligated to provide me with employment and that I am not obligated to accept employment if offered. Nor does receipt of this application imply employment.

I certify that I have fully, honestly and accurately completed the application in its entirety. All statements by me on this application are true, correct and complete to the best of my knowledge. I have not withheld anything whatsoever that would, if disclosed, affect this application unfavorably. I fully understand that any misrepresentation or omission in any part of this application, or in any subsequent other written documents that I am required to provide or complete in the course of employment with St. Joseph's Center may result in the cancellation of this application and, if I am already employed, may result in termination of my employment with St. Joseph's Center.

I hereby release St. Joseph's Center from any liability in making any requests relating to the information contained in this application and/or my suitability for employment and further release St. Joseph's Center for relying on any information received.

I understand that any offer of employment is conditional upon the satisfactory completion of pre-employment tests, including drug testing, physical and tuberculosis test. If, at any time, I would like to review the Drug Free Workplace Policy, I may do so by contacting the Human Resources Department. I understand that a satisfactory drug test is a condition of employment with St. Joseph's Center.

In consideration of my employment, I agree to conform to the policies and procedures of the company and any specific department policies and procedures. I agree that if I accept employment with St. Joseph's Center, I will, as a pre-condition of such employment, produce authentic documents as required establishing my identity and work authorization.

Consumer Report and Investigation:Consumer Report Disclosure
St. Joseph's Center, when considering your application for employment, when making a decision whether to offer you employment, when deciding whether to continue your employment (if you are hired) and when making other employment related decisions directly affecting you, may wish to obtain and use a "consumer report" and/or "investigative consumer report" from a "consumer reporting agency". These terms are defined in the Fair Credit Reporting Act ("FCRA"), which applies to you. As an applicant for employment or an employee of St. Joseph's Center, you are a "consumer" with rights under the FCRA.

A "consumer reporting agency" is a person or business that, for monetary fees, dues or on a cooperative nonprofit basis, regularly assembles or evaluates consumer credit information or other information on consumers for the purpose of furnishing "consumer reports" to others, such as St. Joseph's Center (i.e. Criminal Record Checks through the PA State Police or FBI).

A "consumer report" is a written, oral or other communication of any information by a "consumer reporting agency" bearing on a customer's credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics or mode of living, which is used or collected for the purpose of serving as a factor in establishing a consumer's eligibility for employment purposes.

An "investigative consumer report" is a consumer report or portion thereof in which information on a consumer's character, general reputation, personal characteristics, or mode of living is obtained through personal interviews with neighbors, friends, or associates of the consumer reported on or with others with whom he is acquainted or who may have knowledge concerning any such items of information. The Fair Credit Reporting Act provides you with the right to request, in writing within a reasonable amount of time, a disclosure of the nature and scope of the investigation requested.

If St. Joseph's Center obtains a "consumer report" or "investigative consumer report" about you, and if St. Joseph's Center considers any information in the "consumer report" that directly and adversely affects you, you will be provided with a copy of the "consumer report" before the decision is finalized. You also may contact the Federal Trade Commission about your rights under the FCRA as a "consumer" with regard to "consumer reports", "investigative reports" and "consumer reporting agencies".

I hereby authorize St. Joseph's Center to request an investigative consumer report now and if hired at anytime during my employment, as provided in the Fair Credit Reporting Act. I expressly release and hold harmless each and every person, company or other party that may provide the aforementioned information to St. Joseph's Center.

Submit Your Application
I hereby acknowledge that I have read the above statement and fully understand the terms thereof