* Full Name:

* Address:

* City/State/Zip:

* Phone Number:

Email Address:

Social Security Number (not required):

How did you learn about Philhaven?

Position(s) Applying For:

* 1st Position:

2nd Position:

3rd Position:

Hours Desired (check all that apply):

 Full Time

 Part Time

 Per Diem

 Other

If other or you have a preference, please explain:

Shift Availability (check all that apply)

 Day

 Evening

 Night

 Full Time Every Weekend

 Weekends Only

 Other

If other or you have a preference, please explain:

Location Preferences (check all that apply):

 Any Location

 Berks County

 Cumberland County

 Dauphin County

 Lancaster County

 Lebanon County

 York County

Many client care positions require a driving history free of major violations within the last three years.

Years of Experience in this Field:
Select OneNone1-23-56-10More than 10

* Highest Level of Education Attained:
Select OneHigh School/GEDTrade/SpecialtyAssociatesBachelorsMastersDoctorateMedical DoctorOther

If other, please explain:

Date Available:

Salary Expected:

* Have you been convicted of a felony within the last 7 years:
Select OneYesNo

If yes, please explain:

* Have you ever filed an application with us before:
Select OneYesNo

If yes, please explain:

* Have you ever been employed with us before:
Select OneYesNo

* Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status:
Select OneYesNo

May we contact your present employer:
Select OneYesNo

EDUCATION

Elementary School

School Name:

School Address:

City/State/Zip:

High School

School Name:

School Address:

City/State/Zip:

Years Completed:

Graduated:
Select OneYesNo

Undergraduate Study

School Name:

School Address:

City/State/Zip:

Course of Study:

Years Completed:

Graduated:
Select OneYesNo

Graduation Year:

Type of Degree:

Graduate Study

School Name:

School Address:

City/State/Zip:

Course of Study:

Years Completed:

Graduated:
Select OneYesNo

Graduation Year:

Type of Degree:

Summarize any other skills, training, military experience, and/or qualifications acquired from past employment:

EMPLOYMENT HISTORY

Start with your present or last job. Please include any job, public or private, as well as consulting roles and related military assignments. Provide a complete address. Please list every position held within the last ten years.

Present or Last Job

Employer:

Address:

City/State/Zip:

Phone Number:

Email Address:

Job Title:

Supervisor:

Reason for Leaving:

Employment Dates

From:

To:

Hourly Rate/Salary

Starting:

Final:

Work Performed:

Prior Job

Employer:

Address:

City/State/Zip:

Phone Number:

Email Address:

Job Title:

Supervisor:

Reason for Leaving:

Employment Dates

From:

To:

Hourly Rate/Salary

Starting:

Final:

Work Performed:

Prior Job

Employer:

Address:

City/State/Zip:

Phone Number:

Email Address:

Job Title:

Supervisor:

Reason for Leaving:

Employment Dates

From:

To:

Hourly Rate/Salary

Starting:

Final:

Work Performed:

AUTHORIZATION FOR RELEASE OF INFORMATION

I hereby authorize the release to PHILHAVEN of any and all information relative to my employment, including but not limited to dates of employment, attendance records, performance ratings, rates of pay and eligibility for reemployment. I authorize its release without penalty or liability. A printed copy of this authorization shall be considered as valid as the original.

* Electronic Signature (Type your full name to indicate agreement):

* Today's Date:

PERSONAL REFERENCES

(not relatives or previous supervisors)
First Reference

Name:

Address:

City/State/Zip:

Phone Number:

Email Address:

Second Reference

Name:

Address:

City/State/Zip:

Phone Number:

Email Address:

Third Reference

Name:

Address:

City/State/Zip:

Phone Number:

Email Address:

Fourth Reference

Name:

Address:

City/State/Zip:

Phone Number:

Email Address:

I certify that answers given herein are true and complete to the best of my knowledge.

I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an "at will" nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this "at will" employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of the organization.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.

* Electronic Signature (Type your full name to indicate agreement):

* Today's Date:

PHILHAVEN APPLICATION SUPPLEMENT

In a few sentences, how would you describe your preferred work environment?

Describe one characteristic that you value in yourself and why.

What experience have you had working on a team? Describe your role:

How have you handled the least interesting or least pleasant tasks assigned to you?

How do you cope with sudden deadlines and changes in your workload?

What distinguishes a great employee from a good employee?

How will you contribute to Philhaven's mission?

To include your resume along with this form:

1. Highlight all the text on the resume you want to copy

2. Press 'Cntrl C' to copy (Hold down the Ctrl key and press C)

3. Place the cursor in the RESUME text box displayed below

4. Press 'Cntrl V' to paste the information:

Paste Resume Below:

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