Application

Education and Training History
High School
Graduated*
YesNo
Name and Location (High School)*
Years Attended*
College/Vocational School
Graduated*
YesNo
Name and Location (College/Vocational School)*
Years Attended*
Degree / Area of Study*
Graduate Studies
Graduated*
YesNo
Name and Location (Graduate)*
Years Attended*
Degree / Area of Study*
Licenses and Certifications
Do you have Licenses and Certifications related to the position for which you are applying for?*
YesNo
License/Certification (RN, LSW, CPA, etc.)
Date Issued
MonthDayYear
Date
Expiration
MonthDayYear
Date
Issuing Authority
City & State
License/Certification (RN, LSW, CPA, etc.)
Date Issued
MonthDayYear
Date
Expiration
MonthDayYear
Date
Issuing Authority
City & State

Employment History
Starting with your present or most recent employer, please list in consecutive order all employment. Please list any time during this period that you were unemployed, by stating the nature of your activities. Please provide details, do not write “See Resume”.
Name and Address of Employer*
Phone*
Supervisor*
Job Title*
Start Date (MM/YYYY)*
End Date (MM/YYYY)*
List Major Duties*
Reason for Leaving*
Name and Address of Employer*
Phone
Supervisor
Job Title*
Start Date (MM/YYYY)*
End Date (MM/YYYY)*
List Major Duties*
Reason for Leaving*
Name and Address of Employer*
Phone
Supervisor
Job Title*
Start Date (MM/YYYY)*
End Date (MM/YYYY)*
List Major Duties*
Reason for Leaving*
Have you ever been discharged from a job(s)?*
YesNo
If yes, please provide details, including place(s) of employment, location(s), date(s), supervisor’s name(s) and circumstances of the discharge(s)
Have you applied for other positions with PHMC or an affiliate in the last 6 months?*
YesNo
If yes, which position(s)

Military Service
Have you served in the Military or Reserves?*
YesNo
Branch of Service
From (MM/YYYY)
To (MM/YYYY)
Honorable Discharge
YesNo
Reserve Status
ActiveInactive
Additional Information
Language Skills (spoken and written)
Awards, Honors and Certifications
References
Please list three references other than relatives, that can provide feedback on your abilities, experience, and character. A minimum of one reference must be a former/current manager or supervisor
Name*
Title
Company
Address
Telephone*
E-mail*
Relationship*
Name*
Title
Company
Address
Telephone*
E-mail*
Relationship*
Name*
Title
Company
Telephone*
E-mail*
Relationship*

Applicant Certifications, Disclosures, Waivers and Agreements PLEASE READ THIS STATEMENT CAREFULLY I hereby affirm that the information given by me on this application for employment is complete and accurate. I understand that any falsification or omission either on this application, or otherwise providing false information to PHMC will be grounds for immediate dismissal, no matter when the falsification or omissions is discovered. It is my understanding that as a prerequisite to consideration for employment, I must agree to submit to any post-employment examinations, physical or other, as PHMC may lawfully require. PHMC will pay the reasonable cost of any such examination that may be required. I understand and acknowledge that, should I be employed with PHMC, the employment relationship I have with PHMC will be on an “AT-WILL” basis. This means that I am free to terminate my employment with PHMC at any time with or without cause or notice and that PHMC is similarly entitled to terminate my employment with or without cause or notice.
a. I hereby consent to and authorize PHMC to conduct a background check that includes a search of state and federal abuse and neglect registries and databases, in addition to search of county, state, and federal criminal history records that include a fingerprint-based check. I understand that this consent extends to the release and sharing of such information with Pennsylvania State Police. PHMC also verifies education and employment history. b. I hereby agree to sign a release form to authorize the release of any relevant information to the contracted “Third-party” background screening agency used on behalf of PHMC to conduct the background check. Note: Third-party background screening agencies are defined as consumer reporting agencies under the Fair Credit Reporting Act, and the background screening reports they prepare are defined as "consumer reports." The contracted “Third –party”, obtains information in the “consumer report” that is limited to criminal history reports, education and employment history. PHMC does not conduct credit background checks or obtain credit information; however, PHMC reserves the right to run such consumer reports, if necessary to meet the credentialing requirements of a funding source or regulatory agency. c. I hereby agree to provide all the information necessary to conduct a background check as required by the applicable funding sources or regulatory agencies to obtain the required employment clearance. I also understand that if I fail to return the Release Form and required information to the contracted “Third-party” and the PHMC HR department within 3-5 days of receipt of the written request for the information, that my application for employment will no longer be considered. d. I understand that I am required to abide by all rules and regulations of PHMC. I understand that as a condition of my being hired, I will be asked to submit for review and copying, documents establishing my identity and legal authorization to work in the United States, and, I will also be asked to sign an Form I-9 under penalty of perjury indicating that I am authorized by immigration laws to obtain employment in the U.S. e. I understand that PHMC will make the final employment determination. I also understand that PHMC may terminate the background check or determine not to hire at any stage of the process. I understand that PHMC, in denying employment to an applicant, and reasonably relying on information obtained through a background check, is provided immunity from any action brought by an applicant due to the employment decision. PHMC shall not employ individuals who do not successfully pass the background screening based upon the criteria of the regulatory agencies.
By pressing submit, I have read and agree to the terms and conditions of the Certifications, Disclosures, Waivers and Agreements
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