CONYNGHAM BOROUGH EMPLOYMENT APPLICATION (AN EQUAL OPPORTUNITY EMPLOYER) PERSONAL INFORMATION DATE LAST NAME FIRST NAME MIDDLE INITIAL STREET ADDRESS PO BOX CITY STATE ZIP CODE PHONE NUMBER EMAIL CELL PHONE NUMBER ARE YOU 18 YEARS OR OLDER? YES NO ARE YOU PREVENTED FROM COUNTRY BECAUSE OF VISA OR IMMIGRATION STATUS? YES LAWFULLLY BECOMING EMPLOYED IN THIS NO EMPLOYEMENT DESIRED POSITION DATE YOU CAN START SALARY DESIRED ARE YOU EMPLOYED NOW? IF SO MAY WE INQUIRE OF YOUR PRESENT EMPLOYER? EVER APPLIED TO THIS COMPANY BEFORE? WHERE? WHEN? REFERRED BY EDUCATION NAME AND LOCATION OF SCHOOL YEARS DID YOU GRADUATE? SUBJECTS STUDIED ATTENDED GRAMMAR SCHOOL HIGH SCHOOL COLLEGE TRADE, BUSINESS OR CORRESPONDENCE SCHOOL GENERAL SUBJECTS OF SPECIAL STUDY ORJ RESEARCH WORK SPECIAL SKILLS ACTIVITIES ICIVIC.ATHLETICS ETC) EXCLUDE ORGANIZATIONS, THE NAME OF WHICH INDICATES STATUS, COLOR OR NATION OF ORIGIN OF ITS MEMBER RACE, CREED, SEX, AGE, MARITAL US MILITARY OR NAVAL SERVICE RANK PRESENT MEMBERSHIP IN NATIONAL GUARD OR RESERVES FORMER EMPLOYERS (LIST BELOW LAST THREE EMPLOYERS, STARTING WITH LAST ONE FIRST) DATE NAME AND ADDRESS SALARY POSITION REASON FOR MONTH AND YEAR OF EMPLOYER LEAVING FROM TO FROM TO FROM TO WHICH OF THESE JOBS DID YOU LIKE BEST? WHAT DID YOU LIKE MOST ABOUT THIS. JOB? REFERENCES: GIVE THE NAMES OF THREE PERSONS NOT RELATED TO YOU, WHOM YOU HAVE KNOW AT LEAST ONE YEAR. NAME ADDRESS BUSINESS YEARS ACQUAINTED 1, 2. 3. IN CASE OF EMERGENCY NOTIFY NAME ADDRESS PHONE NO. certify that all information submitted by me on this application is true and complete, and understand that if any false information, omissions, or misrepresentations are discovered, my application may be rejected and, if am employed, my employment may be terminated at any time. In consideration of my employment, agree to conform to the company's rules and regulations, and agree that my employment and compensation can be terminated, with or without cause, and with or without notice, at any time, at either my or the company's option. also understand and agree that the terms and conditions of my employment may be changed, with or without cause, and with or without notice, at any time by the company. I understand that no company representative, other than its president, and then only when in writing and signed by the president, has any authority to enter into any agreement for employment for any specific period of time, or to make any agreement contrary to the foregoing. SIGNATURE DATE DO NOT WRITE BELOW INTERVIEWED BY DATE REMARKS HIRED YES NO POSITION DEPT SALARY/WAGE DATE REPORTING TO WORK APPROVED : IF HIRED EVERYONE UNDER 18 YEARS OF AGE NEEDS WORKING PAPERS All employees having direct contact with children must have child abuse clearances and training. If you already have your clearances and they are not more than 60 months old, you need not apply again. Please provide a copy to the office. Clearances needed for the new child protection laws Search--Keep Kids Safe-DHS.pa.gov CLICK- Child Abuse Clearances Pennsylvania Child Abuse History Clearance. Cost- $13.00 Pennsylvania State Police Criminal History Clearance. Cost - $22.00 Federal Bureau of Investigations (FBI) Criminal History Clearance- fingerprinting $24.95. Must register on line. Service code and identification documents list attached. Fingerprinting done at Leonard's Auto Tag, 996 N. Sherman Court, Hazleton, PA. Fees must be paid at time of applying. The fee charges will be reimbursed to you by Borough Council at the end of the program. Once completed and you receive your clearance, please provide the original to the office. Mandated Reporter Training Training can be done on line. There is no cost and the training takes 3 hours. Keep Kids Safe- click mandated reporter training Choose- The University of Pittsburg's Child Welfare Resources Center Upon completion of the course, your certificate can be printed. Please provide the original to the office. If you have already completed this training. Please provide a copy to the office. Any questions, please call the office at 570-788-4385. IdentoGO PA Department of Human Services - OCYF Use Only Fingerprint Service Code Form Service Name: Employee >-14 Years Contact w/ Children To Schedule your ten-minute fingerprint appointment, simply visit htps/vemrol.cemtopocom and enter the following Service Code 1KG756 Service Code is unique to your hiring/licensing agency. Do not use this code for another purpose. Please bring one of the identification documents from the list below to your enrollment appointment. > Driver's License issued by a State or outlying possession of the U.S. > Driver's License PERMIT issued by a State or outlying possession of the U.S. > ID card issued by a federal, state, or local government agency or by a oft > State ID Card (or outlying possession of the U.S.) with a seal or logo from Territory State the United States > Commercial Driver's License issued by a State or outlying possession of the U.S. or State Agency > Canadian Driver's License > Department of Defense Common Access Card > Employment Authorization Card/ Document (I-766) with Photo > Foreign Driver's License (Mexico and Canada only) > Foreign passport > Military Dependent's Identification Card > Permanent Resident Card or Alien Registration Receipt Card (Form -551) > U.S. Coastguard Merchant Mariner Card > U.S. Military Identification Card > U.S, Passport > Enhanced Tribal dentification Card (for federally recognized U.S. > U.S. Visa issued by the U.S. Department of Consular Affairs fort travel tribes) to the United States or within, or residence within, > Uniformed Services Identification Card (Form DD-1172-2) > Photo ID Waiver for Minors and U.S. Social Security Card or Birth Certificate Don't have access to the Internet? You can still schedule an appointment by calling 844-321-2101 Identification Requirements for Minor Fingerprinting Applicants Ifa minor applicant does not have an identification Service Code form, at the time of the document as listed on their fingerprinting appointment they must present: 1. The Pennsylvania Photo ID Waiver for Minors AND 2. One of the following identification (Check the box for the documentation documents for the minor type presented): Original or certified copy of a birth certificate issued State Bureau of Vital Statistics by the appropriate U.S. territory, the District of or equivalent agency from a U.S. state, record issued Columbia, or a Canadian province. A birth by a hospital is not acceptable under this Original or certified copy of a U.S Department of category. Birth Abroad issued to U.S citizens born State Certification of or FS-545). abroad (Form FS-240, DS-1350, a Original or certified copy of court order with indicating an official change of name and date of birth U.S. territory, the District of name and/or gender from a U.S. state, D Social Security Card Columbia, or Canadian providence. (actual card). PENNSYLVANIA PHOTO ID WAIVER FOR MINORS Legal Name of Minor (First, Middle, Last) DOB (DD/MMYYY) certify that - am the parent or legal of not have a state-issued photo identification guardian card the above-named child. This child does or other Primary Identity Document. confirm that the child present with me is the individual named above. site-location. Must be signed by parent or legal guardian at the time of Do not sign the form in advance. fingerprinting at the fingerprinting Printed Name of Parent or Legal Guardian Signature of Parent or Legal Guardian Date EVERYONE UNDER 18 YEARS OF AGE NEEDS WORKING PAPERS