Application for Employment

Application for Employment

Lycoming-Clinton Counties Commission for Community Action (STEP), Inc.
We consider applicants for positions without regard to race, color, religion, sex, national origin, age, marital or veteran status, the presence of a non-job related medical condition or handicap, or any other legally protected status.
Position applied for:*
Date of application:*

MonthDayYear
Date
Name*

First NameMiddle InitialLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email
example@example.com

Are you legally eligible for employment in the United States? Proof of citizenship or immigration status will be required for completion of I-9 upon employment.*

YesNo
Do you have a means to regularly travel within Lycoming and Clinton counties if a position requires?*

YesNo

Employment History

List below all present and past employment, starting with your most recent. If you need more space, please utilize the additional field provided.

Professional registration/certification
Do you have any professional registration/certification applicable to position for which you are applying?

YesNo
Professional registration/certification
License/certification number (such as Class IV license)
State or agency
Positions that require special registration or certification - proof of above will be required upon hire.

Clearances
All STEP positions require clearances. Do you currently have such documentation from the Pennsylvania Department of Human Services, the Pennsylvania State Police, and/or the FBI?*

YesNo
If yes, please provide a copy of your clearance or proof of applications for clearance with this application. (Proof of application or actual clearances will be required prior to hire for some positions.)

Cancelof

List professional, trade, business or civic activities and offices held. You may exclude memberships which would reveal sex, race, religion, national origin, age, ancestry, or handicap or other protected status.
Please add any information you feel would be beneficial to STEP in evaluating your application.

References

Give name, address, and telephone number of three references who are not related to you and are not previous employers.
I certify that I have not knowingly withheld any facts or circumstances that would detrimentally affect this application. It is agreed that any misrepresentation by me in this application will be sufficient cause for cancellation of an employmemt offer or for dismissal from service if I am employed.

I hereby authorize STEP to contact my former employers or volunteer agencies unless otherwise indicated, to make inquiries regarding my work record, and/or to contact listed schools for the release of records and transcripts.
Signature*
Date*

MonthDayYear
Date

We consider applicants for positions without regard to race, color, religion, sex, national origin, age, marital or veteran status, the presence of a non-job related medical condition or handicap, or any other legally protected status.