First Name Last Name MI
Social Security Number
Street Address
City State Zip Code
E-mail Address Phone
Preferred Method of
Contact
E-mail
Phone
Are you currently a
RACC student?
Yes
No
Which position are you applying for?
If you are under 18 years of age can you furnish a work permit? (Skip this question if you are
over 18 years of age)
Yes
No
Have you applied for
the following
mandatory background
checks?
PA State Police Criminal Record Check
PA Child Abuse History Clearance
FBI Criminal Background Check
Have you served in the
U.S. military?
Yes
No
Branch Dates of Service
Can you, upon employment, submit verification of your legal right to work in the U.S.?
Yes
No
How did you learn of this position? [newspaper (name), employee (name), other (explain)]
Have you filed an application here before?
Yes
No
If you have any relatives working for RACC or any of its grant-funded programs, please provide their names and their
relationship to you
Select the highest level of education you have completed
Some high school
High school equivalent or GED
Associates Degree
Bachelors Degree
Masters Degree
Doctorate
Professional Degree
If you attended college, please indicate the name of the institution, degrees obtained, dates of
completion, major (if applicable), and GPA (optional)
If you attended a trade school, or have other specialized training, please indicate the name of the
institution, certificates obtained, dates of completion, and any other pertinent information
regarding your training
Date Started Date Ended Base Salary
Company Name City/State Phone Number
Job Title Supervisor"s Name
Reason for Leaving
Date Started Date Ended Base Salary
Company Name City/State Phone Number
Job Title Supervisor"s Name
Reason for Leaving
Date Started Date Ended Base Salary
Company Name City/State Phone Number
Job Title Supervisor"s Name
Reason for Leaving
First Name Last Name
Company Position
E-mail Address Phone
First Name Last Name
Company Position
E-mail Address Phone
First Name Last Name
Company Position
E-mail Address Phone
When can you start?
What is your general availability? (check all that apply)
Weekdays
Weekends
Evenings
If you are available evenings, please specify day of the week (check all that apply)
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Please indicate any other restrictions on your availability (For example: not available between
4-6pm during the week, and not available any time on Wednesday)
Will you travel off-campus if your job duties require it?
Yes
No
Will you work overtime if your job duties require it?
Yes
No
Will you undergo a pre-employment physical if required?
Yes
No
Are you currently an active participant in PSERS or SERS?
Yes, I am an active participant in PSERS
Yes, I am an active participant in SERS
No, I am not an active participant in PSERS or SERS
Are you currently receiving pension payments from PSERS or SERS?
Yes, I am receiving pension payments from PSERS
Yes, I am receiving pension payments from SERS
No, I am not receiving pension payments from PSERS or SERS
Additional Information List any other information you would like us to consider. This may include
foreign languages you read/write/speak, organizations you belong to or special
accomplishments, awards, or skills.
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