Valley Community Services

Employment

Valley Community Services is an equal opportunity employer. Admissions, the provision of services, referrals, and employment shall be made without regard to race, color, religious creed, disability, ancestry, national origin, age, or sex.

We are always looking for caring and dedicated individuals who want to make a difference in someone's life.
For employment opportunities, complete the form below and mail it to:
Human Resource Department
Valley Community Services
PO Box 838
Mt. Pleasant, Pa 15666

Valley Community Services

Employment Application

An Equal Opportunity Employer

Valley Community Services does not discriminate on the basis of race, national origin, color, sex, age or disability. It is our intention that all applicants be given equal opportunity and that selection decisions are based on job-related factors.

Answer all questions fully and accurately. All information will be treated confidentially.

Personal Data:

Name: ________________________________________ Telephone Number: ____________________

Last First Middle

Address: ____________________________________________________________________________

Street Address City State Zip Code

Position Applied for: ___________________________________________________________________

Are you above the minimum legal age? _____ Yes _____ No

If you are applying for a job with minimum age requirements, you may be

required to submit proof of age.

Are you legally eligible to work in the United States? _____ Yes _____ No

If hired, you will be required to produce proof of eligibility to work in the

United States, in accordance with the Immigration Reform and Control Act of 1986.

Have you ever been convicted of a felony? _____ Yes _____ No

If yes, please explain:

Eligibility to be hired will not necessarily be affected by a positive

response.

Are you able to perform the essential functions of the job for which you are applying either without accommodations or with a reasonable amount of accommodations? _____ Yes _____ No

General Data:

Have you ever applied at Valley Community Services before? _____ Yes _____ No

If so, when? _____________________

Have you ever been employed by Valley Community Services? _____ Yes _____ No

If so, when? _____________________

Military Data:

Have you ever served in the US Military Services? _____ Yes _____ No

If so, what branch? _____________________________________________________________

Briefly describe service duties: Employment Experience Data: List names of employers in consecutive order with present or last employer listed first. If self employed, please give company name and supply business reference. Continue on separate sheet if necessary.
Employer Information: ____________________ Name, Address & Telephone	Employed: ____________ From: To:	Pay: ____________ Start: End:	Title	Reason for Leaving	Name of Last Supervisor
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