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Employment Application
Personal Information
Last Name
First Name
Middle Initial
Other Name(s) Used
Social Security #
Home Telephone
Other Telephone
Address
Position Applied For
Referred ByEmployee's Name
Are you applying for:
YesNo
Regular, full-time work?
Regular, part-time work?
Temporary/Seasonal Work?
Are you available to work on weekends, as needed?
Are you available to work on holidays, as needed?
Are you available to work overtime, as needed?
Are you able to work different shifts (e.g. swing shift, graveyard shift), if needed?
Have you ever applied to or worked for PHS/SPCA
If yes, list date(s) & job title(s):
Do you have any friends or relatives employed by PHS/SPCA?
If yes, state name(s) & relationship(s):
If hired, what date can you start work?
Employment History

List all employments for the past 10 years, starting with the most recent position. All information must be completed. You may attach a resume but not in place of completing the required information.

Employer 1
Employed From
Employer Name
Employer Address
Supervisor Name
Supervisor Phone
Employed Until
Job Title
Reason for Leaving
Duties & Responsibilities
0 /
Employer 2
Employed From
Employer Name
Employer Address
Supervisor Name
Supervisor Phone
Employed Until
Job Title
Reason for Leaving
Duties & Responsibilities
0 /
Employer 3
Employed From
Employer Name
Employer Address
Supervisor Name
Supervisor Phone
Employed Until
Job Title
Reason for Leaving
Duties & Responsibilities
0 /
General Information
Are you currently employed?
If yes, may we contact your current employer?
If hired, can you furnish proof of age?
If hired, would you have reliable means of transportation to and from work?
Have you ever been terminated or asked to resign from employment?
If yes, please explain:
Will you be able to perform the essential job functions for the position you are applying for with or without reasonable accommodation?
If no, describe the functions that cannot be performed.
If hired, can you present evidence of your US citizenship or proof of your legal right to live and work in the US?
Do you speak, write or understand any foreign language?
If yes, what languages?
Have you obtained any special skills or abilities as the result of service in the military?
If yes, please explain:
Do you have any other experience, training, qualifications or skills that you feel make you especially suited for work at PHS/SPCA?
0 /
File Submission
Cover LetterPlease upload your Cover Letter as a PDF
Upload Cover Letter
ResumePlease upload your Resume as a PDF
Upload Resume
Certification & Authorization

You hereby certify that you have not knowingly withheld any information that might adversely affect your chances for employment and that the answers given by you are true and correct to the best of your knowledge. You further certify that you have personally completed this application.


You understand that any omission or misstatement of material fact on this application or on any document used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery.


You hereby authorize PHS/SPCA to thoroughly investigate your references, work record, education and other matters related to your suitability for employment and, further, authorize the references you have listed to disclose to the company any and all letters, reports and other information related to your work records, without giving you prior notice of such disclosure. In addition, you hereby release PHS/SPCA, your former employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure.


You understand that nothing contained in the application, or conveyed during any interview which may be granted or during your employment, if hired, is intended to create an employment contract between you and PHS/SPCA. In addition, you understand and agree that if you are employed, your employment is for no definite or determinable period and may be terminated at any time, with or without prior notice, at the option of either yourself or PHS, and that no promises or representations contrary to the foregoing are binding on the company unless made in writing and signed by you and the PHS/SPCA's designated representative.

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