Employment Application

Thank you for your interest in Presbyterian SeniorCare as a potential employer. Presbyterian SeniorCare is an Equal Opportunity Employer. All applicants are considered for positions without regard to race, creed, color, religion, sex, sexual orientation, national origin, age, qualified disability or handicap, or veteran status. Based upon the information you have supplied, your application will be reviewed by the appropriate department manager. If there is a need to schedule you for a personal interview, you will be contacted by phone. We regret that we are unable to provide a more personal response to applicants. Your application will be kept on file for one year.

Personal Information

Please fill in required fields.

* Indicates Mandatory Fields
First Name:* Last Name:*
Gender:
Address 1:
Address 2:
City: State:
Zip:
Home Phone: (xxx-xxx-xxxx)
* Please provide at least one phone number		 Cell Phone: (xxx-xxx-xxxx)
E-mail:
Position: If Other:
Recruiting Source: If Other:
If referred by an Employee, please provide Employee name:
Have you filed an application with Presbyterian SeniorCare before? If yes, when?
Have you ever been employed at Presbyterian SeniorCare before?*
      If yes, specify where:
      If yes, specify when:
      If yes, specify the reason you left:
Date available to start:* (MM/DD/YYYY)
Available to work: Full-Time  Part-Time  Shifts  Weekends  Holidays  Temp  
Please specify any days or hours not available to work
Have you been convicted, plead guility or nolo contendere to a crime (violent or otherwise)?
      If yes, please explain:
If yes, describe fully the criminal convictions(s), date of convictions, nature of the offense, your age at the time, and your rehabilitation since the conviction(s). A conviction will not necessarily bar one from employment; however, there are specific criminal convictions that prohibit employment under the Pennsylvania Older Adults Protective Services Act and others that might relate to your suitability for employment in the position for which you have applied.

Questions


1. If under 18 years of age, do you have a work permit? *
      *
2. If not a U.S. citizen, do you have the right to work in the U.S.? *
      *
3. If no, Visa or Alien Reg. #
     
4. Have you been dismissed from employment due to abuse of a client or resident? *
      *

Employment History

List your work experience (starting with your present or most recent employer) for the last 10 years. Please account for all periods of unemployment and military service.

1.
Employer's Full Name: Address:
City: State (U.S. only):
Country: Zip:
From Date:* (MM/YYYY) To Date:* (MM/YYYY)
Supervisor Name:* Phone:* (xxx-xxx-xxxx)
Salary per Job title:*
Type of Work and Duties:*
(Limited to 1000 characters)
Reason for Leaving:*
2.
Employer's Full Name: Address:
City: State (U.S. only):
Country: Zip:
From Date:* (MM/YYYY) To Date:* (MM/YYYY)
Supervisor Name:* Phone:* (xxx-xxx-xxxx)
Salary per Job title:*
Type of Work and Duties:*
(Limited to 1000 characters)
Reason for Leaving:*
3.
Employer's Full Name: Address:
City: State (U.S. only):
Country: Zip:
From Date:* (MM/YYYY) To Date:* (MM/YYYY)
Supervisor Name:* Phone:* (xxx-xxx-xxxx)
Salary per Job title:*
Type of Work and Duties:*
(Limited to 1000 characters)
Reason for Leaving:*
4.
Employer's Full Name: Address:
City: State (U.S. only):
Country: Zip:
From Date:* (MM/YYYY) To Date:* (MM/YYYY)
Supervisor Name:* Phone:* (xxx-xxx-xxxx)
Salary per Job title:*
Type of Work and Duties:*
(Limited to 1000 characters)
Reason for Leaving:*

Education and Training


# Institution Name Years Major Diploma Type Diploma Name Graduate
1.
Comments:
2.
Comments:
3.
Comments:
4.
Comments:

Licenses/Certifications Held


# Type Number State (U.S. Only) Country Expiration Date
(MM/DD/YYYY)
1.
Comments:
2.
Comments:
3.
Comments:
4.
Comments:
General comments (200 characters)

Employment References

Please provide at least two contacts for employment references.

# Name Phone
(xxx-xxx-xxxx)		 Company Name Title Association with Individual Years Known
1.
2.
3.
4.

Applicant Statement

Please check boxes as appropriate.

I certify that the statements made on this application and any supplements are true and correct to the best of my knowledge and belief. I authorize Presbyterian SeniorCare (PSC) to contact any or all of my references for full information regarding my qualifications and suitability for employment, as well as verification of any information I have provided. I understand that any misrepresentation or omission of facts on this application (or supplements to it) will be sufficient cause for rejection of the application or immediate dismissal if discovery is found after my employment. I understand that my employment can be terminated at any time be either PSC or me. If employed by PSC, I agree to abide by its rules and regulations. I agree to take a post-offer medical examination at no personal expense to me. I understand that PSC will obtain a report of criminal history information from the Pennsylvania State Police, and in some cases, the Federal Bureau of Investigation, in accordance with the requirements of the Pennsylvania Older Adults Protective Services Act. I agree to provide the necessary information for these reports.
I accept this statement
I give my permission to any of my prior employers to release any information regarding my work experience and employment, including but not limited to, job performance and disciplinary information. I hereby authorize PSC to conduct this background and reference check and I release PSC and its representatives from liability for seeking, gathering and using such information. I release any individual or entity from any liability whatsoever for providing PSC with any information concerning my qualifications and suitability for employment. I authorize PSC to send a copy of this authorization to my previous employers.
I accept this statement
If you have not been a resident of Pennsylvania at all times for at least the last two years or if you live outside Pennsylvania, PSC will also be required to obtain a criminal history record check from the Federal Bureau of Investigation. You will be required to submit to a full set of fingerprints in addition to the State Police check. PSC will provide you with the necessary forms to initiate the criminal records check. If you do not cooperate with the criminal history records check process, you will not be considered for employment.
I accept this statement
To create a great place for residents to live, employees to work and families and community to feel confident in the services being delivered, Presbyterian SeniorCare staff is expected to demonstrate the following Standards of Behavior:

Positive - Greet everyone with kind words and a smile. Remember to say "please" and "thank you." Ask pleasantly, "What can I do for you?" or "How may I help you?" When thanked, respond with "My pleasure."

Respectful - Treat others as you would like to be treated. Listen to residents, co-workers and others in an open and compassionate manner. Address residents as the very important people (VIP) they are.

Reliable - Think of the needs of residents, co-workers and the general community. Remember you are part of a team and others depend on you. Come to work as scheduled. Show you can be trusted to "get the job done" right.

In The Know - Be a good resource. Know the answers to questions or offer to find someone who does. Share important and accurate informaiton with team members.

Accountable - Look at the "big picture." Think of the impact your actions have on others. Take responsibility to help achieve goals and fulfill the mission.

Pride - Be confident and show a "can-do attitude." Take interest in what other departments and communities are doing and how it affects all of Presbyterian SeniorCare.
I accept this statement

You may be employed on a provisional basis, pending the outcome of the criminal history records check from the FBI, provided that you affirm in writing that you are not disqualified from employment based on a conviction for the prohibitive offenses. If the FBI criminal history records check reveals a conviction for a crime that precludes employment under the law, you will be terminated immediately.

Thank you.