Fillable APPLICATION FOR EMPLOYMENT (Lower Paxton Township)

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APPLICATION FOR EMPLOYMENT (Lower Paxton Township)

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1
APPLICATION FOR EMPLOYMENT
LOWER PAXTON TOWNSHIP
425 Prince Street
Harrisburg, PA 17109
Telephone: 717-657-5600
Fax: 717-724-8311
APPLICANT INFORMATION
Last Name
First
M.I.
Date
Street Address
Apartment/Unit
City
Zip
Home Phone
E-mail Address
Type of Employment Desired:
□ Full Time □Part Time □Seasonal □Temporary
Position Desired:
Date Available for Work:
How did you learn of this position?
If applying for a part-time position, please place an “X” under the day(s) you are available to work and/or list the hours you are
available to work on particular days.
Sun
Mon
Tue
Wed
Thu
Fri
Sat
GENERAL INFORMATION
Have you previously worked for Lower Paxton Township?
□Yes □No
If “Yes,” provide position held and dates of employment.
Are you authorized to work in the United States? □ Yes □ No
(Proof of identity and eligibility to work in the U.S. shall be required upon employment)
If you are under 18 years of age, can you provide required proof of your eligibility to work? □ Yes □ No
DRIVER RECORD INFORMATION
Do you possess a valid driver’s license? □ Yes □ No
Driver's License Number:
State of Issue:
Expiration Date:
Operator Class:
Endorsement:
If “No,” reason: □ License Suspended Suspension Expiration Date: □ License Revoked
□ Provisional License □ Never Licensed to Drive □ Other:
2
EDUCATION
High School
Address
Course of Study
Diploma (Y/N)
College
Address
Course of Study
Degree
Credits Earned
GPA
Honors/Awards
Graduate School
Address
Course of Study
Degree
Credits Earned
GPA
Honors/Awards
Other
Address
Course of Study
Degree
Credits Earned
GPA
Honors/Awards
PROFESSIONAL LICENSES AND/OR CERTIFICATES
Lower Paxton Township seeks only information on professional licenses and/or certificates that are relevant to the position(s) the
applicant is seeking to obtain.
Type
State Issued
Date Issued
Expiration Date
License No.
Verification
Type
State Issued
Date Issued
Expiration Date
License No.
Verification
Have your professional licenses and/or certificates ever been
suspended, revoked, or placed on probation?
□Yes □No
If “Yes,” when and for what reason?
MILITARY SERVICE
Branch of U.S. Armed Forces:
Type of Discharge:
Dates of Service (MM/DD/YYYY)
From: To:
Are you a widow or widower of a deceased veteran or the spouse of a veteran who is 100% disabled?
□Yes □No If “Yes,” describe the circumstances.
3
EMPLOYMENT HISTORY
YOU MUST COMPLETE THIS SECTION OF THE APPLICATION (a resume may be attached in addition to providing the
requested information). START WITH PRESENT OR MOST RECENT EMPLOYER.
May we contact your current employer at this time? □Yes □No
Employer
Address
Telephone Number
Dates of Employment
Position Held
Starting Pay
Final Pay
Supervisor’s Name/Title
Work Performed:
Reason for Leaving:
Are you currently on "Lay-off" status and subject to recall? □Yes □No
Employer
Address
Telephone Number
Dates of Employment
Position Held
Starting Pay
Final Pay
Supervisor’s Name/Title
Work Performed:
Reason for Leaving:
Are you currently on "Lay-off" status and subject to recall? □Yes □No
Employer
Address
Telephone Number
Dates of Employment
Position Held
Starting Pay
Final Pay
Supervisor’s Name/Title
Work Performed:
Reason for Leaving:
Are you currently on "Lay-off" status and subject to recall? □Yes □No
Employer
Address
Telephone Number
Dates of Employment
Position Held
Starting Pay
Final Pay
Supervisor’s Name/Title
Work Performed:
Reason for Leaving:
Are you currently on "Lay-off" status and subject to recall? □Yes □No
4
ADDITIONAL EMPLOYMENT/BACKGROUND INFORMATION
Have you ever been discharged from a job? □Yes □No
If “Yes,” provide name of employer and reason.
Have you ever quit a job after being notified that you would be fired? □Yes □No
If “Yes,” provide name of employer and reason.
Describe any specialized work-related training you received or apprenticeships you served.
Please include any additional information, volunteer work, school activities, or training received that is relevant to the position for
which you are applying:
SPECIALIZED SKILLS
I have skills in and am familiar with the following areas and/or equipment:
□Cash Register
□Access or Excel Spreadsheets
□Drafting
□Heavy Equipment
□Copier/Scanner
□Databases
□Reading of Blueprints
□Landscaping
□Dictation Equipment
□Power Point
□Carpentry
□Mechanic
□Multi-line Telephone
□Accounting/Bookkeeping
□Electrical Work
□Mowing Equipment
□Personal Computer
□Computer Programming
□Plumbing
□Truck Driving
□Word Processing WPM
Other:
List experiences on other job-related equipment and machines, any additional skills you have, and/or any processes with which you
are familiar that are not listed above.
REFERENCES
List three supervisors, instructors or other individuals who can evaluate your work performance.
(Do not list friends or relatives.)
Name:
Telephone Number:
Address:
Name:
Telephone Number:
Address:
Name:
Telephone Number
Address:
5
ADDITIONAL
INFORMATION
Please read the following statements and acknowledge your understanding below.
It is the policy of Lower Paxton Township (the Township) not to hire in any full-time capacity within the same department the
spouse, child, parent, sibling, aunt, uncle, niece, or nephew of any existing full-time employee. Do you have any such relatives
currently working for the Township?
□Yes □No If “Yes," state name(s), relationship(s), position(s), and department(s) where relative(s) is(are) employed.
The Township adheres to the tenets of the Drug Free Workplace Act and has zero tolerance for the use of unlawful drugs
in the workplace. The Township is a smoke-free workplace. Smoking is prohibited in Township-owned buildings and
vehicles.
It is the Township's policy that full-time Township employment shall be the primary job of all full-time employees. The
Township does not attempt to prohibit employees from engaging in secondary employment. However, it is the position
of the Township that secondary employment cannot interfere with the effective performance of municipal duties and
that secondary employment cannot be of a type that would reflect adversely upon the Township's public image. An
employee should inform his/her supervisor or manager if he/she obtains secondary employment while working.
Persons who are actively seeking elected office within the municipality are not eligible for employment with Lower
Paxton Township.
Certain municipal employees may be covered by the Federal Hatch Act. If you become such an employee, and
subsequently run for the public office, or now hold public office, your employment will be terminated.
Certain criminal offenses may disallow employment of individuals in a department based on the date, charge,
count, and grade of the offense.
I have read and understand the information stated above.
□Yes □No
PLEASE READ CAREFULLY BEFORE SIGNING
I swear that this application and any and all documents to supplement or support it contain no falsifications or
misrepresentations, nor do they omit or conceal any material facts. I swear that all information provided by me is true and
complete to the best of my knowledge. I further acknowledge that the discovery, at any time, of any falsification,
misrepresentation, omission, or concealment will result in my disqualification from consideration for employment or, if
employed by Lower Paxton Township, in my dismissal from employment.
Further, I hereby consent to any lawful valid test, screen, examination or background investigation which Lower Paxton
Township may require of all applicants for similar employment. I understand that this investigation may include inquiries
to any or all current and former employers, whether or not cited by me on my application; references cited by me on my
application; other person(s) who may have knowledge of my suitability for the employment I seek; and criminal background
checks.
I understand that any employment will be on a six-month probationary basis. Any individual who is hired may voluntarily
leave employment upon proper notice and may be terminated by Lower Paxton Township for any reason. I understand
that any oral or written statements to the contrary are hereby expressly disavowed and should not be relied upon by any
prospective or existing employee.
Lower Paxton Township is an Equal Opportunity Employer. Employment with Lower Paxton Township is based strictly
upon the qualifications of the individual as related to the work requirements of the position. These criteria are applied
without regard to age, race, color, religion, sex including sexual orientation and gender identity, national origin, disability,
genetic information, protected veteran status or any other classification protected by Federal, state, or local law. Applicants
requiring an accommodation in the application process should contact Human Resources.
___________________________________________________ ________________________________
Signature of Applicant Date
LOWER PAXTON TOWNSHIP
FCRA Authorization to Obtain a Consumer
Report (Background/Credit Check)
Pursuant to the federal Fair Credit Reporting Act, I hereby authorize Lower Paxton Township and its
designated agents and representatives to conduct a comprehensive review of my background through a
consumer report and/or an investigative consumer report to be generated for employment, promotion,
reassignment or retention as an employee. I understand that the scope of the consumer report/investigative
consumer report may include, but is not limited to, the following areas: verification of Social Security
number; current and previous residences; employment history, including all personnel files; education;
references; credit history and reports; criminal history, including records from any criminal justice agency
in any or all federal, state or county jurisdictions; birth records; motor vehicle records, including traffic
citations and registration; and any other public records.
I understand further that such pursuit shall be carried out in compliance with all applicable law (including,
but not limited to, Title VII of the Civil Rights Act of 1964; the Americans with Disabilities Act of 1990 (ADA),
including changes made by the ADA Amendments Act of 2008 (P.L. 110-325); and the Vietnam Era
Veterans’ Readjustment Assistance Act of 1974, as amended by the Jobs for Veterans Act of 2002, 38
U.S.C. 4212).
Yet further, I understand that all information obtained will be used solely for the lawful assessment of my
suitability for employment and will not be disclosed concurrently or subsequently except as necessary to
the pursuit of assessment, or in compliance with lawful subpoena, unless disclosure for another purpose is
explicitly authorized by me, in writing.
Finally, I hereby understand that failure by Lower Paxton Township to obtain information sufficient for
assessment of my suitability for employment may, itself, be grounds for denial of said employment, whether
or not there be evidence of misrepresentation by me or by any other party.
I, ________________________________, authorize the complete release of these records or data
pertaining to me that an individual, company, firm, corporation or public agency may have. I hereby
authorize and request any present or former employer, school, police department, financial institution or
other persons having personal knowledge of me to furnish Lower Paxton Township or its designated agents
with any and all information in their possession regarding me in connection with an application of
employment. I am authorizing that a photocopy of this authorization be accepted with the same authority
as the original.
I understand that, pursuant to the federal Fair Credit Reporting Act, if any adverse action is to be taken
based upon the consumer report, a copy of the report and a summary of the consumer’s rights will be
provided to me.
___________________________________ _____________________
Signature Date
Good Government for a Great Community
LOWER PAXTON TOWNSHIP
Background Check Requirements
A Pennsylvania State Police record check is required on all prospective hires. Depending upon the length
of an individual’s Pennsylvania residency, a Federal Bureau of Investigation (FBI) criminal background
check may be required.
Additionally, and in accordance with Act 153 of the Pennsylvania Child Protection laws, prospective
employees that are deemed to be 1) mandatory reporters and/or have direct contact with children, or 2) are
responsible for the care, supervision and control of children, are required to have a favorable Pennsylvania
Child Abuse History Clearance in addition to a favorable Pennsylvania State Police record check and a
favorable Federal Bureau of Investigation criminal background check. Certain criminal offenses may
disallow employment of individuals in a department based on the date, charge, count, and grade of the
offense.
Information on obtaining the required background checks is provided below. Please follow the instructions
on the respective websites. The hiring manager will inform you when it is time to begin the background
check process. These background clearances must be dated within five (5) years of date of hire and
must be repeated every five (5) years.
Pennsylvania State Police Record Check
https://epatch.state.pa.us
Pennsylvania Child Abuse History Clearance
https://www.compass.state.pa.us/cwis/public/home
FBI Background Check
https://uenroll.identogo.com/
Appointments to be fingerprinted are not required, but pre-registration is required and can
be done either online or by phone. Use Service Code 1KG738 (Pennsylvania Department
of Human Services (DHS) – Child Care Services/Program Employee or Contractor) when
registering.
To register online, please visit https://uenroll.identogo.com/.
To register by phone, please call 1-844-321-2101.
For fingerprinting locations in your area:
https://www.identogo.com/locations
A convenient location on the East Shore is listed below:
IdentoGO
1800 Linglestown Road
2
nd
Floor, Suite 201
Harrisburg, PA 17110-3345
Hours: Monday through Friday
9:30 a.m. – 11:30 a.m.
1:00 p.m. – 3:00 p.m.
Juveniles (14-17 years of age) may be exempt from an FBI criminal background check if a
resident of Pennsylvania for ten (10) years and his/her parent or guardian affirms in writing
that the minor has not committed a prohibited offense. You may request an exemption form
from your hiring manager if this situation applies to you.
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APPLICATION FOR EMPLOYMENT (Lower Paxton Township)

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Completed 18 November 2020

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