Fillable Printable Application for Employment Form

Application for Employment Form

APPLICATION FOR EMPLOYMENT

Position ________________________________________ Date ______/______/_____

Name (Last) (First) (M) Are you a United States citizen or an alien

authorized to work in the United States?

Yes

1 No 1

Address Telephone Number

Home Work

( ) ( )

GED High School College Degrees

Yes

1 1 2 3 4 1 2 3 4 5 6 7

Have you ever been employed by the Commonwealth of Pennsylvania?

Yes

1 No 1

Agency (ies)

Personal

Education

Employment

Special qualifications and skills with computers and office equipment:

Circle Highest Year of Education Completed

Are your education/employment records listed under another name/names?

If so please list:

Social Security No.

The Public Utility Commission is an equal opportunity employer dedicated to a policy of nondiscrimination in employment with-

out regard to race, color, religion, creed, gender, national origin, age, physical and/or mental disability, ancestry, pregnancy,

marital, veteran, or any other legally protected status. We value the contribution that the diversity of applicants can bring to the Public

Utility Commission. If you require assistance or a reasonable accommodation in completing this application or any aspect of the

application process, including interviewing, please contact the Human Resources Office.

Applicant’s Statement

Please read carefully before signing.

I hereby affirm that the information provided on this Application and accompanying resume (if any) is true and correct to the

best of my knowledge. I also agree that any falsified information or significant omission may disqualify me from further

consideration for employment and may result in my discharge if discovered at a later date. I agree that the Public Utility

Commission shall not be liable in any respect if my employment is terminated because of false statements, answers or omissions.

I authorize the Public Utility Commission to investigate all statements made in this Application, contained in my resume or

made by me in any interview or other document. I authorize the Public Utility Commission to contact my current or most recent

employer for employment verification. I authorize the Public Utility Commission to investigate all statements in this Application

and to secure any necessary information from employers, references, educational institutions and certifying entities. I hereby release

these employers, references, educational institutions and certifying entities from any and all liability arising from their giving or

receiving information regarding my employment history, academic credentials or qualifications, and/or my

suitability for employment.

I understand that I may receive a job offer which is conditioned upon demonstration of my ability to perform the essential

functions of the position for which I have applied.

I understand that this Application will be considered active for a period of one hundred and twenty (120) days. Should I wish

to be considered for employment beyond this period of time, I acknowledge that I must complete another application form or

request in writing that my application continue to be considered.

Signature _____________________________________________ Date ________/_______/________

For Commonwealth Employees Only

I authorize the Public Utility Commission to review my Official Personnel Folder in the Department

of _____________________________________. My Employee Number is __________________________

Signature _____________________________________________ Date ________/_______/________

Name and Address of Employer Full time 1 Part time 1

Reason for leaving

Job title Name of immediate supervisor and telephone number

( )

List employment record beginning with present or last period of employment over the past 5 years:

Name and Address of Employer Full time 1 Part time 1

Reason for leaving

Job title Name of immediate supervisor and telephone number

( )

Name and Address of Employer Full time 1 Part time 1

Reason for leaving

Job title Name of immediate supervisor and telephone number

( )

Duties

Have you ever quit a job after being notified that you would be fired?

Yes

1 No 1

References: List three persons who are not related to you and who have definite knowledge of your qualifications and fitness for the

position for which you are applying. Do not repeat names of supervisors. Consideration for employment may be delayed until

three individuals can be contacted.

Are you subject to any visa or immigration status which will prevent lawful employment?

Yes

1 No 1

Have you ever been convicted of a felony or misdemeanor? If yes, please explain the nature of the conviction, the date, sentence

(if any) and any other relevant information (Conviction of a criminal offense is not a bar to employment in all cases. Each case is

considered on its merits.)

Yes

1 No 1

Note: If your answer to any of the above is yes, give details, show names and addresses (including zip codes) of employers,

approximate dates, and reasons in each case.

Full name Relationship Present business or home address Business or Telephone

Occupation

( )

Have you ever been fired or asked to resign from a job?

Yes

1 No 1

Answer the following:

Please explain all periods of self-employment and any gaps in your employment history.

Personal Data

The information requested below will be kept confidential and will not affect your chances for employment. Your cooperation in

providing accurate information is important. This information is voluntary; you are not required to complete this form. Your

answers will be used for research purposes and to help insure equal employment opportunities. Please check the appropriate

response to each question. Thank-you for your assistance.

Name

Sex Date of Birth

Male 1 Female 1 Month Day Year

1. 1 Black: (Not of Hispanic Origin): Persons having origins in any of the Black groups of Africa.

2. 1 Hispanic: Persons of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish culture or origin,

regardless of race.

3. 1 White: (Not Hispanic Origin): Persons having origins in any of the original peoples of Europe, North Africa, or the

Middle East.

4. 1 American Indian or Alaskan Native: Persons having origins in any of the original peoples of North America, and who

maintain cultural identification through tribal affiliation or community recognition.

5. 1 Asian or Pacific Islander: Persons having origins in any of the original peoples of the Far East, Southeast Asia, the

Indian Subcontinent, or the Pacific Islands. This area includes, for example, China, Japan, Korea, the Philippine Islands,

and Samoa.

6. 1 Other: (Specify).

Name and Address of Employer Full time 1 Part time 1

Reason for leaving

Job title Name of immediate supervisor and telephone number

( )

List employment record beginning with present or last period of employment over the past 5 years:

Name and Address of Employer Full time 1 Part time 1

Reason for leaving

Job title Name of immediate supervisor and telephone number

( )

Name and Address of Employer Full time 1 Part time 1

Reason for leaving

Job title Name of immediate supervisor and telephone number

( )

Duties

Have you ever quit a job after being notified that you would be fired?

Yes

1 No 1

References: List three persons who are not related to you and who have definite knowledge of your qualifications and fitness for the

position for which you are applying. Do not repeat names of supervisors. Consideration for employment may be delayed until

three individuals can be contacted.

Are you subject to any visa or immigration status which will prevent lawful employment?

Yes

1 No 1

Have you ever been convicted of a felony or misdemeanor? If yes, please explain the nature of the conviction, the date, sentence

(if any) and any other relevant information (Conviction of a criminal offense is not a bar to employment in all cases. Each case is

considered on its merits.)

Yes

1 No 1

Note: If your answer to any of the above is yes, give details, show names and addresses (including zip codes) of employers,

approximate dates, and reasons in each case.

Full name Relationship Present business or home address Business or Telephone

Occupation

( )

Have you ever been fired or asked to resign from a job?

Yes

1 No 1

Answer the following:

Please explain all periods of self-employment and any gaps in your employment history.