Fillable APPLIC PLEASE NOTE: Complete ALL parts of the (County of Centre)

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APPLIC PLEASE NOTE: Complete ALL parts of the (County of Centre)

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File type: PDF

U.S.A. forms for County of Centre

BROWSE COUNTY OF CENTRE (PA) FORMS

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APPLIC
PLEASE NOTE: Complete ALL parts of the application. If you have no information to enter in a section, please write N/A.
Personal Information
Last Name
First Name
MI
Mailing Address (Street)
City, State, and Zip Code
Home Phone
Cell Phone
Email Address
Today’s Date
Position(s) Applying For
Date Available to Start
Work Desired:
Full-Time Part-Time On-Call/Occasional
Will you accept shift work if required by the job? Yes No
Have you had prior employment with Centre County Government? Yes No
If yes, what department(s)?________________________________________Dates_____________________________
Do you have relatives currently working for Centre County Government? Yes No
If
yes, please provide their name, their relationship to you, and their employing department:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Have you ever served for any branch of the US Military, and are you a Veteran?
Yes No Veteran Status must be confirmed by DD-214 or other military documentation if requesting Veteran’s preference.
Branch: ______________________________________________ Years of Service: ___________________________
Employees must be 18 years of age to drive a Centre County vehicle. If the job you are
applying for requires driving, can you meet this requirement? N/A Yes No
Can you drive if the job requires it?
N/A Yes No
I certify that I am authorized to work in the United
States Yes No
Will you provide the fee for a background record check if required? Yes No
www.centrecountypa.gov
Please return application to:
Human Resources
Willowbank Building
420 Holmes Street, Rm. 334
Bellefonte, PA 16823
Phone: (814) 355 - 6748
_________________________ (Last, First, Middle Initial)
Employment History
Please list current or most recent employer first
Employer
From (mo./yr.)
To (mo./yr.)
Salary
Job Title
Address (street, city, state, zip code)
Phone
Supervisor
May we contact this employer? Yes No
Primary Job Duties:
Reason For Leaving
Employer
From (mo./yr.)
To (mo./yr.)
Salary
Job Title
Address (street, city, state, zip code)
Phone
Supervisor
May we contact this employer? Yes No
Primary Job Duties:
Reason For Leaving
Employer
From (mo./yr.)
To (mo./yr.)
Salary
Job Title
Address (street, city, state, zip code)
Phone
Supervisor
May we contact this employer? Yes No
Primary Job Duties:
Reason For Leaving
Employer
From (mo./yr.)
To (mo./yr.)
Salary
Job Title
Address (street, city, state, zip code)
Phone
Supervisor
May we contact this employer? Yes No
Primary Job Duties:
Reason For Leaving
_________________________ (Last, First, Middle Initial)
Training, Certifications, Licenses and/or Memberships (if applicable)
Use the space below to summarize any additional information necessary to describe your full
qualifications for the specific position for which you are applying (optional)
Education
High School
Did you graduate? Yes No
Address
Diploma
GED
Technical School / Community College
Did you graduate? Yes No
Years Completed
Address
Diploma/Degree
Major
College or University
Did you graduate? Yes No
Years Completed
Address
Diploma/Degree
Major
Other College, University, or Graduate School
Did you graduate? Yes No
Years Completed
Address
Diploma/Degree
Major
_________________________ (Last, First, Middle Initial)
1.
Name: Title:
Company Name:
Phone: E-mail:
2.
Name: Title:
Company Name:
Phone: E-mail:
3.
Name: Title:
Company Name:
Phone: E-mail:
PLEASE READ CAREFULLY BEFORE SIGNING
I hereby certify that all of the information provided by me in this application (or any other
ac
companying documents) is
correct, accurate and complete to the best of my knowledge. I understand that falsification or misrepresentation or omission
of any facts in said documents will be cause for denial of employment or include termination of
employmen
t regardless of
timing or circumstances of discovery.
I understand that submission of an application does not guarantee employment. I further understand that employment obtained
with Centre County Government is employment at will, for no specified
durati
on and may be terminated either by Centre
County Government or myself at any time, with or without cause or notice. I understand that none of the documents, policies,
procedures, actions, statements of Centre County Government representatives used during the employment process is
deemed a contract of employment real or implied.
In consideration for employment with Centre County Government; if employed, I agree to conform to the rules,
regulations, policies and procedures of Centre County Government. I understand as a condition of employment, all
offers of employment are contingent upon satisfactory completion of pre-employment screenings, which may include,
but is not limited to, a criminal history record check through the Pennsylvania State Police P.A.T.C.H. system, drug
screening and medical examination. The conviction of a crime will not automatically result in a denial of employment.
The nature and gravity of the offense, whether it is job related, and when it occurred will be considered.
I understand that unsatisfactory results from,
ref
usal to cooperate with, or any attempt to affect the results of these
pre
–
employment checks will result in my withdrawal of any employment offer or termination of employment if already employed.
I hereby authorize any and all schools, former employers,
re
ferences, courts and any others who have information about
me to provide such information to Centre County Government and/or any of its representatives, agents or
vendors
, and I
release parties involved from any and all liability for any and all damage that may result from providing such information.
BY SIGNING BELOW, I ACKNOWLEDGE THAT I UNDERSTAND AND AGREE TO THE ABOVE STATEMENTS.
Signature Date
Centre County Government is an equal opportunity employer. We consider applicants for all positions without regard
to race, color, religion, gender, age, marital
sta
tus, veteran eligibility, sexual orientation, disability, national origin, or
any other legally protected status. No question on this application is asked for the purpose of disclosing any
applicant’s legally protected status. Applicants requiring accommodation in the application or hiring process should
contact the Human Resources Office.
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signature
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EEO Additional Application Information Survey
Regulations require that Centre County collect certain data specifically for our Equal Employment Opportunity
reporting and planning. We are requesting your cooperation in completing this self-identification form. This
information is collected from all applicants on a voluntary basis and is kept in a separate file in the Human Resources
department for reporting purposes only. It will not be sent to the hiring department.
Applicant Name: _____________________________________________ Date: ______________________________
Last, First MI
Gender: ☐Male ☐Female Date of Birth: __________ /__________ /________________
Race/Ethnic Classification:
☐White (Not Hispanic or Latino): Persons having origin in any of the original peoples of Europe, North Africa
or the Middle East
☐Black or African American (Not Hispanic or Latino): Person having origins in any of the Black racial groups of
Africa
☐Hispanic or Latino: Persons of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish
culture or origin, regardless of race.
☐Asian (Not Hispanic or Latino: Persons having origins in any of the original peoples of the Far East, Southeast
Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia,
Pakistan, the Philippine Islands, Thailand and Vietnam.
☐Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) – Persons having origins in any of the
peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
☐American Indian or Alaska Native (Not Hispanic or Latino): Persons having origins in any of the original
peoples of North and South America (including Central America), and who maintain tribal affiliation or
community attachment.
☐Two or More Races (Not Hispanic or Latino) – All persons who identify with more than one of the above five
races.
If you are applying for an opening in the Office of Aging, are you over the age of 60 and requesting Age preference?
☐Yes ☐No
Please tell us how you heard about the opening at Centre County Government:
☐Website
☐Newspaper Ad
☐Private Employment Agency
☐College Recruiting Office
☐State Employment Office (Careerlink)
☐County Job Posting Boards
☐Employee Referral
☐Other – Please specify: __________________________________
If you require accommodations in the application or interview process or if you have
questions about this form or the information requested, please contact Human Resources at
(814)355-6748 or at humanresources@centrecountypa.gov.
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APPLIC PLEASE NOTE: Complete ALL parts of the (County of Centre)

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Completed 21 January 2021

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