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Corporate Office Employment Application Form

Corporate Office Employment Application Form

Presbyterian Homes serves the Presbytery of Lake Erie (Erie, Pennsylvania).

Corporate Office

1225 School Road
Erie, PA 16505

Corporate Office Phone #: (814) 314-1700
Fax: (814) 314-1749

Applicant Information

Name
Address
City
State
ZIP
Phone
Cell Phone
Email Address
How did you hear about Presbyterian Homes?
Position applying for
Type of employment desired	Full-time Part-time Per diem Check all that apply
Hours available to work	Days Evenings Nights Check all that apply
If you are under 18 and it is required, can you furnish a work permit?
If no, please explain.
Have you ever applied for or worked for any Presbyterian Home?
If yes, list facility, plus give date(s) and position(s).
Is this application a request for reemployment following an extended military leave of absence from this company?	If yes, additional information may be requested.
Are you legally eligible for emplyment in this country?
Date available for work
What is your desired salary range/hourly rate?
Have you ever pled guilty or no contest to, or been convicted of a crime?	Answering yes to either part of this question does not constitute an automatic bar to employment. Factors such as date of the offense, seriousness and nature of the violation, rehabilitation, and position applied for will be taken into account.
If yes, please provide date(s) and details.
Are you able to perform the "essential functions" of the job for which you are applying (with or without reasonable accommodation)?	This question is not designed to elicit information about an applicant's disability. Please do not provide information about the existence of disability, particular accommodation, or whether accommodation is necessary. These issues may be addressed at a later stage to the extent permitted by law.

Employment History

Starting with your most recent employer, provide the following information.

Employer 1
Phone
Address
City
State
ZIP
Starting job title/final job title
Supervisor and title
May we contact for reference?
Please summarize the type of work performed and job responsibilities for this employer.
Dates employed From
To
Employer 2
Phone
Address
City
State
ZIP
Starting job title/final job title
Supervisor and title
May we contact for reference?
Please summarize the type of work performed and job responsibilities for this employer.
Dates employed From
To
Employer 3
Phone
Address
City
State
ZIP
Starting job title/final job title
Supervisor and title
May we contact for reference?
Please summarize the type of work performed and job responsibilities for this employer.
Dates employed From
To

Skills and Qualifications

Starting with your most recent employer, provide the following information.

Do you have any of the following licenses and/or certificates?	CNA LPN R.N. Check appopriate options.
Computer Skills	Word Excel Presentation Email Internet Other Check appopriate options.

Educational Background

Starting with your most recent school attended, provide the following information.

School 1	Include City and State
Years Completed
Completed
GPA
Major/Minor
School 2	Include City and State
Years Completed
Completed
GPA
Major/Minor
School 3	Include City and State
Years Completed
Completed
GPA
Major/Minor

References

List names and telephone numbers of three business/work references who are not related to you and are not previous supervisors. If not applicable, list three school or personal references who are not related to you.

Contact 1 Name
Title
Relationship to you
Telephone
Email
# years known
Contact 2 Name
Title
Relationship to you
Telephone
Email
# years known
Contact 3 Name
Title
Relationship to you
Telephone
Email
# years known
Have you been referred to us by an existing employee?
If YES, whom?

Image Verification	This is here to keep robots from submitting this form.

Applicant Statement

I certify that all information I have provided in order to apply for and secure work with Presbyterian Homes is true, complete, and correct.

I expressly authorize, without reservation, Presbyterian Homes to contact and obtain information from all references(personal and professional), employers, public agencies, licensing authorities, and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume, or job interview. I hereby waive any and all rights and claims I may have regarding Presbyterian Homes for seeking, gathering, and using truthful and non-defamatory information, in a lawful manner, in the employment process and all other persons, corporations, or organizations for furnishing such information about me.

I understand that Presbyterian Homes does not discriminate in employment and no question on this application is used for the purpose of limiting or eliminating any applicant from consideration for employment on any basis prohibited by applicable local, state, or federal law.

I understand that this application remains current for only 30 days. At the conclusion of that time, if I have not heard from Presbyterian Homes and still wish to be considered for employment, it may be necessary for me to reapply and fill out a new application.

If I am hired, I understand that I am free to resign at any time, with or without cause and with or without prior notice, and Presbyterian Homes reserves the same right to terminate my employment at any time, with or without cause and with or without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no employee of Presbyterian Homes is authorized to make any assurances to the contrary and that no implied oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by Presbyterian Home's President.

I also understand that if I am hired, I will be required to provide proof of identity and legal authorization to work in the United States and that federal immigration laws require me to complete an I-9 Form in this regard.

Presbyterian Homes does not tolerate unlawful discrimination in its employment practices. No question on this application is used for the purpose of limiting or excluding an applicant from consideration for employment on the basis of his or her sex, race, color, religion, national origin, citizenship, age, disability, or any other protected status under applicable federal, state, or local laws. Presbyterian Homes likewise does not tolerate harassment based on sex, race, color, religion, national origin, citizenship, age, disability, or any other protected status. Presbyterian Homes takes all complaints of harassment seriously and all complaints will be investigated promptly and thoroughly.

I understand that any information provided by me that is found to be false, incomplete, or misrepresented in any respect, will be sufficient cause to (1) eliminate me from further consideration for employment, or (2) may result in my immediate discharge from Presbyterian Homes, whenever it is discovered.

DO NOT SUBMIT THIS FORM UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT.

I certify that I have read, fully understand, and accept all terms of the foregoing Applicant Statement.

Also, please feel free to submit a cover letter, resume, and references via e-mail.

Corporate Office Employment Application Form