Employment Application

By completing this application you are applying for employment at Jefferson Manor Health Center located in Brookville, Pennsylvania.

First Name Middle Name Last Name
City State ZIP
Home Phone Cell Phone Email

Position desired Salary requested When can you be available to begin (MM/DD/YY)
What time of day would you like to work? Are you interested in full-time or part-time work? How were you referred to Jefferson Manor?
Have you ever applied or been employed by us in the past? YES NO
If YES, please explain.
List any friends or relatives employed by Jefferson Manor

Record of Education
School Name School Address Course of study Highest grade completed? Did you graduate? List diploma or degree
List other skills, experiences or qualifications which you feel would especially benefit our team

Record of Employment
Dates Employed Name & Address of employer Job Title Salary Reason for Leaving Supervisor's Name
Which of these jobs did you like best and why?
Which of these jobs did you like least and why?
Give a brief description of the work performed & your responsibilities in the positions mentioned above
Have you ever been convicted of or pled guilty to a felony or misdemeanor? YES NO
If YES, please explain.
Have you lived in Pennsylvania for the last two years? YES NO
If no, please tell us where you lived.
Do you have a legal right to work in the United States? YES NO
"Under the Immigration Control and Reform Act of 1986, any new employee (whether U.S. Citizen or resident alien) must provide at the time of employment, proof of identity, such as a driver's license with photograph, and authorization to be employed, i.e. birth certificate, social security card, U.S. passport, certificate of U.S. Citizenship or naturalization, resident alien card. If an employee is not able to do so, the employee will be discharged immediately."

Personal References
Full Name Address Phone Occupation Years known

Applicant: read this information carefully before signing

I certify that the answers given in this application and in the employment interview(s) are true and complete to the best of my knowledge.

Jefferson Manor Health Center is hereby authorized to make any investigation of all statements in the application, my personal history, educational background, military record, motor vehicle records, criminal records and credit history through their choice. I further authorize my former schools and personal references to provide any information they have regarding me. I hereby release all employers, schools and references from any liability for providing information concerning me.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I also understand that I will be required to take and successfully pass a post-offer of employment physical, a PPD screening for tuberculosis and a criminal history background check. I understand that a criminal history background check will be requested from the PSP and/or the FBI. I also understand that my employment is provisional and continued employment is based upon the information to be received from the criminal justice agency. If the clearance request indicates convictions for crimes that prohibit my employment under Act 169 of 1996 and Act 13 of 1997, I understand that my employment must be terminated in compliance with state law. To the best of my knowledge I have never been convicted of a crime that would prohibit my employment at Jefferson Manor Health Center.

In consideration of my employment, I agree to conform to the rules and regulations of my employer and that my employment and compensation can be terminated with or without cause and with or without notice at any time at the option of either my employer or myself. I understand that no company representative other than the administrator has any authority to enter into any agreement for employment for any specified period of time or make any agreement contrary to the foregoing. Jefferson Manor Health Center is an Equal Opportunity Employer and administers all personnel practices without regard to age, religion, sex, color, race, national origin, disability, sexual orientation, gender identification, marital status, veteran status or any other category under applicable law. Employment opportunities shall be provided for applicants with disabilities and reasonable accommodations shall be made to meet the physical or mental limitations of qualified applicants or employees.

There is no guarantee of a job offer or a job interview in completing this application blank. The application must be completely filled out in order for it to be considered for employment. If the information provided on the application can not be satisfactorily verified by employment reference checks, the application could be considered as incomplete. Due to the large number of applications we receive and the competitive nature of our employment process, specific reasons for employment decisions will not be released.

I also understand that this is NOT a secure website and I can send my resume and information via US mail to the address below if I do not wish to submit this information over an unsecured network. (Jefferson Manor, 417 Rte 28, Brookville, PA 15825)

By typing my name here I understand all above information and wish to be contacted with regard to my employment interest.