Employment Application Posted: Tuesday, July 1st, 2014 by Barb Keller in Join us at Peter Becker Community Name First Last Email Address(s) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Have you lived at any other residences outside of the Commonwealth of Pennsylvania in the past 24 months?YesNoIf you answered "Yes" to the question above, please list previous addressPrimary PhoneAlternate PhoneIs your age under 18?YesNo(Federal regulations prohibit anyone under the age of 18 from working in hazardous occupations.)Are you a U.S. citizen or legally authorized to work in the U.S.?YesNoPosition DesiredType of Employment PreferencesFull-TimePart-TimeFloat PoolSeasonalAnyShift PreferencesDay ShiftEvening ShiftNight ShiftAnyDo you have any relatives who are currently or were previously employed at PBC?YesNoIf you answered "Yes" to the question above, please list name(s)If you are applying for a position that requires driving, do you have a valid driver's license?YesNoWere you previously employed at PBC?YesNoIf you answered "Yes" to the question above, please list start and end dates and locationHave you ever applied to PBC before?YesNoWhy are you interested in working at Peter Becker Community?*Have you ever been dismissed from a job due to abuse of a resident or client?YesNoIf you answered "Yes" to the question above, please explainAre you currently subject to a non-compete or employment agreement with another employer?YesNoAdditional information you feel may be helpful to us in considering your application. This could include specialized training or courses you have completedUpload a file(s). If you prefer, please upload your resumeEducation and TrainingHigh School/Prep or GED. Proof of GED or high school diploma is required for all positions in Personal Care.CPR Certified?YesNoACLS Certified?YesNoPlease list any other certificationsHave you ever been excluded from providing services to Medicare or Medicaid patients/residents or clients?YesNoIf yes, for how long and when, if ever, were you reinstated?Have you ever been convicted of a crime? Include all pleas of "guilty" or "no contest"YesNoIf yes, please explain fully. This information will not necessarily bar an applicant from employment and, therefore, any uncertainty should be resolved in favor of disclosure.Please see information on the Employment FAQs section of the website for further information.My signature below certifies that all statements and information given herein are correct and accurate. I understand that any false answers or statements made by me on this application, any supplement thereto or in connection with the above-mentioned investigations may be grounds for refusal of employment, invalidate my employment or, if employed, grounds for immediate discharge. In consideration of Peter Becker Community's evaluation of my suitability for employment, I hereby authorize Peter Becker Community to perform all checks of my credentials as allowed by law including, but not limited to, discussions with employers, supervisors, co-workers, friends, business associates, or other individuals that Peter Becker Community in its sole discretion, believes they have relevant information regarding my suitability for employment. I further authorize Peter Becker Community to perform the following checks on my credentials; State Criminal Record Check and/or Federal Bureau of Investigation Criminal Background Check, and such other checks as Peter Becker Community deems appropriate. I agree to complete any post-offer physical evaluations that Peter Becker Community may require including a pre-employment physical and testing for illegal or unauthorized substances. I understand that any offer of employment is contingent upon my successfully passing the physical evaluation requirements and the background investigation. I agree not to assert any claims or causes of action of any kind against Peter Becker Community, its agents, its employees, or any individuals or companies contacted by Peter Becker Community as part of its investigation, from any and all claims, demands, damages, actions, causes of action, or suits of any kind of nature whatsoever arising from Peter Becker Community’s investigation of my credentials. I acknowledge that Peter Becker Community has made no representation of any kind as to whether employment will be offered at conclusion of its investigation. If I am offered and accept employment with Peter Becker Community, I agree to abide by the rules and the policies of Peter Becker Community and understand that my employment is at will and terminable at anytime for any reason either by myself or by Peter Becker Community. My signature below acknowledges that I have read and understand the entire application and agree to the terms and conditions outlined above. Applicant SignatureTyping your name here constitutes your signature
