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Employment Application
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Date
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Position You Are Applying For
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Full-time or Part-time
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Full-time
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Date Available to Begin
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MM slash DD slash YYYY
Can you perform essential functions of the job you are applying for. with or without reasonable accommodations?
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Yes
No
If no, please describe:
If reasonable accommodations are necessary, please describe the accommodations needed:
Are you are least 18 years of age or older (if no, you must present a State of Pennsylvania Work Permit)?
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Yes
No
Have you previously worked for the Diocese of Allentown?
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Yes
No
If yes, dates employed?
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Position:
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Are you applying to be a driver?
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Yes
No
Do you have a vaild driver's license?
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Yes
No
Have you had your driver's license suspended or revoked in the last three years?
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Yes
No
If yes, please explain:
Education
Please complete the following information, if applicable to the position you are applying for.
High School / GED
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Course of Study / Major
Diploma, Degree, Certificate Received
High School Address
College or University
Course of Study / Major
Diploma, Degree, Certificate Received
College or University Address
Vocational or Business
Course of Study / Major
Diploma, Degree, Certificate Received
Vocational or Business Address
Nursing Education
Course of Study / Major
Diploma, Degree, Certificate Received
Nursing Education Address
List any Special Skills and Qualifications for this Position:
References
Please list three professional references.
Reference 1 Name
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Relationship
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Company Name
Phone
*
Address
Reference 2 Name
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Relationship
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Company Name
Phone
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Address
Reference 3 Name
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Relationship
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Company Name
Phone
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Address
Employment History
Please provide previous employment information, beginning with the most recent.
Are you currently employed?
Yes
No
Current/Most Recent Employer
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Phone
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Address
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Immediate Supervisor & Title
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Job Title
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Responsibilities
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Dates Employed From
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Reason for Leaving
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May we contact your previous supervisor for a reference?
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Yes
No
Next Most Recent Employer
Phone
Address
Immediate Supervisor & Title
Job Title
Responsibilities
Dates Employed From
Reason for Leaving
May we contact your previous supervisor for a reference?
Yes
No
Previous Employer
Phone
Address
Immediate Supervisor & Title
Job Title
Responsibilities
Dates Employed From
Reason for Leaving
May we contact your previous supervisor for a reference?
Yes
No
Sign & Date
Consent
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I hereby affirm that the information on this application (and accompanying resume, if any) is true and complete. I understand that any false or misleading information, representations, or omissions may disqualify me from further consideration for employment and may result in termination even if discovered at a later date. If hired, I agree to conform to the rules and regulations of the Diocese of Allentown. If hired, I understand that my employment will be on an at-will basis, which means that it can be terminated at any time, with or without cause and with or without notice, at the option of either myself or the Diocese of Allentown.
Signature
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Date
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