Personal Information
Application Information
Education
Employment History
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 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
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Attach your resume
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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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