COUNTY OF BERKS
APPLICATION FOR EMPLOYMENT
___
Berks County Jail System
1287 County Welfare Road
Leesport, PA 19533
jail@countyofberks.com
Courthouse/Services Center
633 Court Street
Reading, PA 19601-3584
hr@countyofberks.com
www.co.berks.pa.us
Berks Heim Nursing and Rehabilitation
1011 Berks Road
Leesport, PA 19533
berksheim@countyofberks.com
Qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age,
marital or veteran status, sexual orientation, political affiliation, or disability.
Date of Application
Position Desired
Referral Source:
Advertisement (Please Specify) _________________________
Employment Agency Friend
Relative
Other
Personal Information:
Name
Last First Middle
Address
Number Street State Zip Code
Phone No.
Social Security Number
Have you filed an application here within the past two years?
Have you ever been employed here before?
Are you legally eligible to work in the United States?
Yes
Yes
Yes
Availability:
No
No
No
Date
Are you available to work?
Date available to start?
If required by the position would you be able to work:
Have you ever been convicted of a felony?
If yes, ex
plain:
Full-Time
Part-Time
(Conviction will not necessarily disqualify an applicant from employment)
Yes No
Evening hours (2
nd
or 3
rd
shift)?
Weekends?
Are you available to work overtime if asked?
Are you on lay-off and subject to recall?
Can you travel if a job requires it?
Some positions within the County of Berks require
a valid drivers license. Can you meet this requirement if necessary?
_____ Yes _____ No
_____ Yes _____ No
_____ Yes _____ No
_____ Yes _____ No
_____ Yes _____ No
_____ Yes _____ No
City
County website
(Please Specify) _________________________
Cell Phone Email
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High School
Business
Trade/Tech
School or Other
College/University Graduate/Professional
School Name
Years Completed:
9 10 11 12
Diploma/Degree
Describe Course of
Study:
Describe specialized
training, apprenticeship
skills, internships and
extra-curricular activities
Honors, awards, and
scholarships received
Skills and Qualifications:
Describe any skills appropriate for the work you are seeking such as computer/typing skills, fluency in languages, machine
operation, etc. Also include any licenses, certifications, or registrations you currently hold.
List professional, trade or business organizations to which you belong and offices held. Exclude groups which indicate
race, color, religion, sex, national origin, age, marital or veteran status, sexual orientation, political affiliation, or
disabilit
y
.
Education:
1 2 3 4
1 2 3 4
1
2 3 4
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Employment Experience:
List each job held. Start with your present or most current job. If you need additional space, please continue on a separate
sheet of paper.
Employer #1
Employer #2
Employer #3
Employer #4
DATES
From
To
HRLY.RATE/SALARY
Start Final
Work Performed
Work Performed
Work Performed
Work Performed
DATES
DATES
DATES
From
To
From
To
From
To
HRLY. RATE/SALARY
HRLY. RATE/SALARY
HRLY. RATE/SALARY
Start Final
Start Final
Start Final
Address
Job Title
Supervisor
Reason for Leaving
Supervisor
Address
Job Title
Reason for Leaving
Address
Job Title
Supervisor
Reason for Leaving
Address
Job Title
Supervisor
Reason for Leaving
Give name, address, and telephone number of three professional references not related to you.
1.
2.
3.
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Veterans:
Do you wish to claim Veterans Preference? (Proof of Honorable Discharge Required)YesNo
Special Employment Notice to Disabled Veterans, Vietnam Era Veterans, and Individuals with Physical or
Mental Disabilities
Government contractors are subject to Section 402 of the Vietnam Era veterans Readjustment Act of 1974, which
requires that they take affirmative action to employ and advance in employment qualified disabled veterans and
veterans of the Vietnam Era, and Section 503 of the Rehabilitation Act of 1973, as amended, which requires
government contractors to take affirmative action to employ and advance in employment qualified handicapped
individuals.
If you are a disabled veteran, or have a physical or mental disability, you are invited to volunteer this information. The
purpose is to provide information regarding proper placement and appropriate accommodation to enable you to
perform the job in a proper and safe manner. This information will be treated as confidential. Failure to provide this
information will not jeopardize or adversely affect any consideration you may receive for employment.
If you wish to be identified, please sign below.
Disabled Individual Disabled Veteran Vietnam Era Veteran
Signed
Agreement:
If I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice, and the County
of Berks reserves the same right to terminate my employment at any time, with or without cause and without prior notice,
except as may be required by law. This application does not constitute an agreement or contract for employment for any
specified period or definite duration.
I hereby authorize the County of Berks to thoroughly investigate my references, work records, education, criminal history, and
other matters related to my suitability for employment and, further, authorize my current and former employers to disclose to
the company any and all letters, reports and other information pertaining to my employment with them, without giving me
prior notice of such disclosure. In addition, I hereby release the County of Berks my current and former employers, and all
other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in
any way related to such investigation or disclosure.
I understand that if offered employment, the offer is contingent on my passing a pre-employment alcohol and drug screen and
a pre-employment ph
ysical. By signing this application, I voluntarily agree to submit to a pre-employment alcohol/drug
screen and pre-employment physical upon receipt of a verbal offer of employment. I understand that failure to pass the
alcohol/drug screen and/or physical will result in withdraw of the employment offer.
I certify that the answers given herein are true and complete to the best of my knowledge.
In the event of employment, I understand that false or misleading information given in
my application or interview(s) may
result in discharge. I also understand, that if hired, I will be required to abide by all rules and regulations of the County.
(initial)
(initial)
(initial)
Signature of Applicant
AN EQUAL EMPLOYMENT OPPORTUNITY EMPLOYER M/F/V/D
Berks County complies with the Drug-Free Workplace Act of 1989
Revised 12/2015
Date
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Request for Job Applicant Information
The County of Berks is an equal opportunity and affirmative action government
contractor. In compliance with government regulations we are required to record
numbers of job applicants by sex and ethnic category. We ask that you indicate your race
or national origin and sex.
You are not required to provide this information. Your application for employment will
be considered in the same manner whether or not you fill out this form. This information
will not be kept with your application and will be used only in accordance with state and
federal regulations.
Check One: Check One:
___ Female ___ Hispanic/Latino
___ Male ___ Asian
___ Black/African American
___ Native American/Alaska Native
___ Native Hawaiian/Pacific Islander
___ White
___ Two or More Races
Job Title(s) Applied for:
Date of Job Application:
If you have any questions about the government requirements or this request, please
contact the Human Resources Department at 610-478-6118.
Submit
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