Personal Information

Application Information

Education

Employment History

References

  • Personal Info
  • Application
  • Education
  • Employment
  • References

Applicant Personal Information

Full Name

Have you ever used any other names or aliases, including maiden, married names and previously married names?

If yes, please list entire name(s) used.

Social Security Number

Current Address

City

State

Zip Code

Email Address

Home Phone Number

Cell Phone Number

Are you at least 18 years of age?

Are you legally authorized to work in the United States?

Application Information

Position of Interest

Referral Source

Date available for employment

Expected Salary

Have you previously interviewed with PCA?

Were you ever employed by PCA?

Are there limitations on the locations you are willing to work?

If yes, please specify.

Are there any limitations on the hours you can work?

If required, can you work any shift?

If required, are you willing to travel?

Do you have a valid driver's license?

High School

High School Graduate or Equivalent?

High School Name

College

College Graduate?

Dates Attended

Degree / Major

School Name and Location

Business / Trade / Vocational School

Business / Trade / Vocational Graduate?

Dates Attended

Degree / Major

School Name and Location

Professional License Certification

Professional License Certification?

Dates Attended

Degree / Major

School Name and Location

Acquired Skills

Acquired Skills

Please describe selected skills.

Other experience, skills, languages, or qualifications, which you consider relevant to your ability to perform the position for which you are applying.

Most Recent Employment

Present or most recent employer

Street Address

Dates Employed

Supervisor’s Name

Phone Number

Job Title

Major Duties

Reason for Leaving

May we contact the above now?

Previous Employer

Previous Employer

Street Address

Dates Employed

Supervisor’s Name

Phone Number

Job Title

Major Duties

Reason for Leaving

Previous Employer 2

Previous Employer 2

Street Address

Dates Employed

Supervisor’s Name

Phone Number

Job Title

Major Duties

Reason for Leaving

Military Status

Military/Veteran Status

Employment History

Do you have any relatives employed by PCA? ( A relative is a mother, father, mother-in-law, father-in-law, husband, wife, son, daughter, son-in-law, daughter-in-law, grandparent, grandchild, brother, sister, brother-in-law, sister-in-law, stepparent, stepchild, stepsibling, aunt, uncle, niece, nephew or cousin of an employee or employee’s spouse)

Have you ever been disciplined disciplined or discharged by any employer for absenteeism, tardiness, failure to notify your company when absent, or any other attendance-related reason?

Have you ever been disciplined or discharged by any employer for theft, unauthorized removal of company property, or related offenses?

Have you ever been disciplined or discharged by any employer for fighting, assault, or related offenses?

Have you ever been disciplined or discharged by any employer for insubordination?

Have you ever been disciplined or discharged by any employer for possession or use of alcohol or drugs at work?

Have you ever been terminated by any employer or asked to resign from employment for any reason?

If you answered Yes to any of the above statements, please explain, including dates, location, i.e., city, county, state.

References 1

Name

Street Address

Occupation

Phone Number

Reference Type

Reference 2

Name

Street Address

Occupation

Phone Number

Reference Type

Reference 3

Name

Street Address

Occupation

Phone Number

Reference Type

Attach Resume

Attach your resume

Pre-Employment Statement

PRE-EMPLOYMENT STATEMENT: PLEASE READ CAREFULLY I certify that the information contained in this application is correct to the best of my knowledge. I understand that falsification of this information or failure to provide complete and accurate information is grounds for dismissal. I authorize the Employment/Professional/Personal references listed to give you any and all information concerning my previous employment and any pertinent information they may have. I voluntarily give Phillips & Cohen Associates, Ltd. the right to make a thorough investigation of my past employment, activities, and education, and I agree to cooperate in such investigation. I release from all liability or responsibility all persons, companies or corporations supplying any information to Phillips & Cohen Associates, Ltd.. Note: In accordance with the FAIR CREDIT REPORTING ACT (Pre-Notification), I understand that as part of Phillips & Cohen Associates, Ltd.'s procedure for processing my application, an investigative report may be made whereby information is obtained through personal interviews with third parties, such as family members, business associates, financial sources, friends, neighbors, or others with whom I am acquainted. In consideration of my employment, I agree 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 the Company or myself. By typing my full name below, I attest to all of the above. My typed name below should serve as my electronic signature.

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