3410 W 12th St, Erie, PA 16505

Employment Application

We are an Equal Opportunity Employer. It is our policy to abide by all Federal, State, and Local laws concerning discrimination in employment. No questions in this application is intended to elicit information in violation of any such law nor will any information obtained in response to any questions be used in violation of any such law.

Employment Type:*
Were you previously employed by this organization?

If Yes, What are the dates you worked:

List any relatives or friends Working for this organization (include names and relationships):


Work Experience 1
Work Experience 2
Work Experience 3
Work Experience 4
May we contact the above employers:
How did you learn of this position?

Special Skills and Qualifications:

Professional References (no family members or friends)
Miscellaneous Information
Can you verify your legal rights to work in the U.S. by providing a birth certificate, proof of U.S. Citizenship, or by some other means?
If you are under 18 can you furnish a work permit?
Are you able to perform the job (s) for which you are applying for?

APPLICANT’S CERTIFICATION – Please read carefully before signing*

Employment at Will: If employed, I understand and agree that such employment may be terminated at any time, without prior notice, and that my employment will not be governed by any expressed or implied contract but is at-will.

I certify that to the best of my knowledge and belief, the answers given by me to the foregoing questions and the statements made by me in this application are correct and complete. I understand that misrepresentation or omission of facts in this application may result in my discharge.

I hereby give the Employer the right to investigate all references unless otherwise stated herein.

For Personal Care Attendant applicants: I understand that I will be dismissed from employment if I have been named as a perpetrator of a “founded” or “indicated” report of child abuse, or have been convicted of any crimes in violation of the Older Adult Protective Services Act, Act 28 of 1995, Act 169 of 1996, Act 13 of 1997, or equivalent crime in another state.

I understand that submission to a criminal conviction check is a condition of employment with the company. Failure to submit to such a check will result in ineligibility for hire or my employment being terminated.

I understand that this employer is a Drug-Free Workplace employer.