Emp.

APPLICATION FOR EMPLOYMENT (PA)

Equal Employment Opportunity Policy: We are committed to providing equal employment opportunities to all employees and applicants without regard to race, religion, color, sex, national origin, citizenship status, uniform member status, age, creed, ancestry, use of a guide or support animal, disability or any other protected status in accordance with all applicable federal, state, and local laws.

Position Desired

Date

First/Last/Middle
/ /

Present Address Street and Number/City/State/Zip - How long at Present Address
/ / / - yrs.months.

Previous Address Street and Number/City/State/Zip - How long at Previous Address
/ / / - yrs.months.

Telephone No.

Email Address:

Note: Answering "Yes" to the following four questions does not constitute an automatic bar to employment. Factors such as age and time of the offense, seriousness and nature of the violation, and rehabilitation will be taken into account. (Do not include minor traffic citations and arrests or convictions which have been sealed or expunged in answering this question.)

Have you ever worked for this company before? If Yes please give dates and position

Have you ever pled guilty, or no contest to, or been convicted of a felony? If Yes please give dates and details

Have you ever pled guilty, or no contest to, or been convicted of a misdemeanor resulting in imprisonment within the last seven years? If Yes please give dates and details

Have you been arrested for any matters for which you are out on bail or on your own recognizance pending trial? If Yes please give dates and details

Record of Previous Employment
Please list the name of your present or previous employers in chronological order with present or last employer listed first. Be sure to account for all periods of time including military service and any period of unemployment. If self-employed, give firm name and supply business references.

Present or Last Employer Address
City, State, Zip
Telephone

Employed (From/To)
Pay (Start/Finish)

Title or Position
Name and Title of Supervisor

Exact Reason for Leaving

Present or Last Employer Address
City, State, Zip
Telephone

Employed (From/To)
Pay (Start/Finish)

Title or Position
Name and Title of Supervisor

Exact Reason for Leaving

Present or Last Employer Address
City, State, Zip
Telephone

Employed (From/To)
Pay (Start/Finish)

Title or Position
Name and Title of Supervisor

Exact Reason for Leaving

Have you ever been terminated or asked to resign from any job? If Yes please explain the circumstances

Please explain fully any gaps in your employment history:

May we contact your current employer? If No, please explain:

Please indicate any actual experience, special training and qualifications that you have which you feel are relevant to the position for which you are applying.

Have you ever used another name? Is any additional information relative to change of name, use of an assumed name, or nickname necessary to enable a check on your work and educational record? If yes, please explain.

If hired can you furnish proof that you are over 18 years of age?

Do you have adequate transportation to and from work?

How many days of work have you missed in the last three years due to reasons other than paid holidays and vacation? YearDays / / YearDays / / YearDays

Education

School Name: Years Completed Diploma/Degree Course of Study/Major Specialized Training, Skills, or Extra-Curricular Activities

High School

College/Univ.

Grad/Professional

Trade or Correspondence

Other :

Other :

Personal References
Please list persons who know you well - exclude previous employers or relatives

Name Occupation Address (Street, City, State) Telephone Number Number of Years Known

APPLICANT'S STATEMENT & AGREEMENT

In the event of my employment to a position in this Company, I will comply with all rules and regulations of this Company. I understand that the Company reserves the right to require me to submit to a test for the presence of drugs in my system prior to employment and at any time during my employment, to the extent permitted by law. I also understand that any offer of employment may be contingent upon the passing of a physical examination. I consent to the disclosure of the results of any physical examination and related tests to the Company. I also understand that I may be required to take other tests such as personality and honesty tests, prior to employment and during my employment. I understand that should I decline to sign this consent or decline to take any of the above tests, my application for employment may be rejected or my employment may be terminated. I understand that bonding may be a condition of hire. If it is, I will be so advised either before or after hiring and a bond application will have to be completed.

I understand that the company may investigate my driving record and my criminal record and that an investigative consumer report may be prepared whereby information is obtained through personal interviews with my neighbors, friends, personal references, and other with whom I am acquainted. This inquiry includes information as to my character, general reputation, personal characteristics and mode of living. I understand that I have the right to make a written inquiry within a reasonable period of time to receive additional detailed information about the nature and scope of this investigation. I further understand that the Company may contact my previous employers and I authorize those employers to disclose to the Company all records and information pertinent to my employment with them. In addition to authorizing the release of any information regarding my employment, I hereby fully waive any rights or claims I have or may have against my former employers, their agents, employees and representatives, as well as other individuals who release information to the Company, and release them from any and all liability, claims, or damages that may directly or indirectly result from the use, disclosure, or release of any such information by any person or party, whether such information is favorable or unfavorable to me. I authorize the persons named herein as personal references to provide the Company with any pertinent information they may have regarding myself.

I hereby state that all the information that I provided on this application or any other documents filled out in connection with my employment, and in any such interview is true and correct. I have withheld nothing that would, if disclosed, affect this application unfavorably. I understand that if I am employed and any such information is later found to be false or incomplete in any respect, I may be dismissed. I understand if selected for hire, it will be necessary for me to provide satisfactory evidence of my identity and legal authority to work in the United States, and that federal immigration laws require me to complete an I-9 Form in this regard.

I hereby state that all the information that I provided on this application or any other documents filled out in connection with my employment, and in any such interview is true and correct. I have withheld nothing that would, if disclosed, affect this application unfavorably. I understand that if I am employed and any such information is later found to be false or incomplete in any respect, I may be dismissed. I understand if selected for hire, it will be necessary for me to provide satisfactory evidence of my identity and legal authority to work in the United States, and that federal immigration laws require me to complete an I-9 Form in this regard.

I further agree and acknowledge that the Company and I will utilize binding arbitration to resolve all disputes that may arise out of the employment context. Both the Company and I agree that any claim, dispute, and/or controversy that either I may have against the Company (or its owners, directors, officers, managers, employees, agents and parties affiliated with its employee benefit and health plans) or the Company may have against me, arising from, related to, or having any relationship or connection whatsoever with my seeking employment with, employment by, or other association with the Company shall be submitted to and determined exclusively by binding arbitration under the Federal Arbitration Act, in conformity with the procedures of the Pennsylvania Consolidated Statutes, Chapter 42, Section 7301 of et seq., including Section 7309, and all of the Act's other mandatory and permissive rights to discovery. Included within the scope of this Agreement are all disputes, whether based on tort, contract, statute (including, but not limited to, any claims of discrimination and harassment, whether they be based on the Pennsylvania Human Relations Act, Title VII of the Civil Rights Act of 1964, as emended, or any other state or federal law or regulation), equitable law, or otherwise, with exception of claims arising under the National Labor Relations Act which are brought before the National Labor Relations Board, claims for medical and disability benefits under the Pennsylvania Workers' Compensation Act. Pennsylvania Unemployment Compensation claims, or as otherwise required by state or federal law. However, nothing herein shall prevent me from filing and pursuing proceedings before the Pennsylvania Human Relations Commission, or the United States Equal Employment Opportunity Commission (although if I choose to pursue a claim following the exhaustion of such administrative remedies, that claim would be subject to the provisions of this Agreement.) Further, this Agreement shall not prevent either me or the Company from obtaining provisional remedies to the extent permitted by Pennsylvania law (either before the commencement of or during the arbitration process), pending final resolution of the dispute pursuant to this Agreement. In addition to any other requirements imposed by law, the arbitrator selected shall be a retired Pennsylvania Commonwealth Court Judge, or otherwise qualified individual to whom the parties mutually agree, and shall be subject to disqualification on the same grounds as would apply to a judge of such court. All rules of pleading, all rules of evidence, all rights to resolution of the dispute by means of motions for summary judgement and judgement on the pleadings, shall apply and be observed. Resolution of the dispute shall be based solely upon the law governing the claims and defenses pleaded, and the arbitrator may not invoke any basis (including but not limited to, notions of "just cause") other than such controlling law. The arbitrator shall have the immunity of a judicial officer from civil liability when acting in the capacity of an arbitrator, which immunity supplements any other existing immunity. Likewise, all communications during or in connection with the arbitration proceedings are privileged. As reasonably required to allow full use and benefit of this agreement's modifications to the Act's procedures, the arbitrator shall extend the times set by the Act for the giving of notices and setting of hearings. Awards shall include the arbitrators written reasoned opinion. I understand and agree to this binding arbitration provision, and both I and the Company give up our right to trial by jury of any claim I or the Company may have against each other.

If hired, I agree as follows: My employment and compensation is terminable at-will, is for no definite period, and my employment and compensation may be terminated by either the Company (employer) or me at any time and for any reason whatsoever, with or without good cause.

This is the entire agreement between the Company and me regarding dispute resolution, the length of my employment, and the reasons for termination of employment and this agreement supersedes any and all prior agreements regarding these issues. It is further agreed and understood that any agreement contrary to the foregoing must be entered into, in writing, by myself and the President of the Company. No supervisor or representative of the Company, other than its President, has any authority to enter into any agreement for employment for any specified period of time or make any agreement contrary to the foregoing. Oral representations made before or after you are hired to not alter this Agreement.

If any term or provision, or portion of this Agreement is declared void or unenforceable it shall be severed and the remainder of this Agreement shall be enforceable.

If you have any questions regarding this statement, please ask a Company representative before signing. I hereby acknowledge that I have read the above statements and understand the same.

I HAVE READ THE ABOVE STATEMENT AND AGREEMENT.
I CERTIFY THAT ALL OF THE INFORMATION THAT I HAVE PROVIDED ON THIS APPLICATION IS TRUE AND ACCURATE.

This application will be considered active for a maximum of thirty (30) days. If you wish to be considered for employment after that time you must reapply.

Education
School Name:	Years Completed	Diploma/Degree	Course of Study/Major	Specialized Training, Skills, or Extra-Curricular Activities
High School
College/Univ.
Grad/Professional
Trade or Correspondence
Other :
Other :

Personal References Please list persons who know you well - exclude previous employers or relatives
Name	Occupation	Address (Street, City, State)	Telephone Number	Number of Years Known




APPLICANT'S STATEMENT & AGREEMENT In the event of my employment to a position in this Company, I will comply with all rules and regulations of this Company. I understand that the Company reserves the right to require me to submit to a test for the presence of drugs in my system prior to employment and at any time during my employment, to the extent permitted by law. I also understand that any offer of employment may be contingent upon the passing of a physical examination. I consent to the disclosure of the results of any physical examination and related tests to the Company. I also understand that I may be required to take other tests such as personality and honesty tests, prior to employment and during my employment. I understand that should I decline to sign this consent or decline to take any of the above tests, my application for employment may be rejected or my employment may be terminated. I understand that bonding may be a condition of hire. If it is, I will be so advised either before or after hiring and a bond application will have to be completed. I understand that the company may investigate my driving record and my criminal record and that an investigative consumer report may be prepared whereby information is obtained through personal interviews with my neighbors, friends, personal references, and other with whom I am acquainted. This inquiry includes information as to my character, general reputation, personal characteristics and mode of living. I understand that I have the right to make a written inquiry within a reasonable period of time to receive additional detailed information about the nature and scope of this investigation. I further understand that the Company may contact my previous employers and I authorize those employers to disclose to the Company all records and information pertinent to my employment with them. In addition to authorizing the release of any information regarding my employment, I hereby fully waive any rights or claims I have or may have against my former employers, their agents, employees and representatives, as well as other individuals who release information to the Company, and release them from any and all liability, claims, or damages that may directly or indirectly result from the use, disclosure, or release of any such information by any person or party, whether such information is favorable or unfavorable to me. I authorize the persons named herein as personal references to provide the Company with any pertinent information they may have regarding myself. I hereby state that all the information that I provided on this application or any other documents filled out in connection with my employment, and in any such interview is true and correct. I have withheld nothing that would, if disclosed, affect this application unfavorably. I understand that if I am employed and any such information is later found to be false or incomplete in any respect, I may be dismissed. I understand if selected for hire, it will be necessary for me to provide satisfactory evidence of my identity and legal authority to work in the United States, and that federal immigration laws require me to complete an I-9 Form in this regard. I hereby state that all the information that I provided on this application or any other documents filled out in connection with my employment, and in any such interview is true and correct. I have withheld nothing that would, if disclosed, affect this application unfavorably. I understand that if I am employed and any such information is later found to be false or incomplete in any respect, I may be dismissed. I understand if selected for hire, it will be necessary for me to provide satisfactory evidence of my identity and legal authority to work in the United States, and that federal immigration laws require me to complete an I-9 Form in this regard. I further agree and acknowledge that the Company and I will utilize binding arbitration to resolve all disputes that may arise out of the employment context. Both the Company and I agree that any claim, dispute, and/or controversy that either I may have against the Company (or its owners, directors, officers, managers, employees, agents and parties affiliated with its employee benefit and health plans) or the Company may have against me, arising from, related to, or having any relationship or connection whatsoever with my seeking employment with, employment by, or other association with the Company shall be submitted to and determined exclusively by binding arbitration under the Federal Arbitration Act, in conformity with the procedures of the Pennsylvania Consolidated Statutes, Chapter 42, Section 7301 of et seq., including Section 7309, and all of the Act's other mandatory and permissive rights to discovery. Included within the scope of this Agreement are all disputes, whether based on tort, contract, statute (including, but not limited to, any claims of discrimination and harassment, whether they be based on the Pennsylvania Human Relations Act, Title VII of the Civil Rights Act of 1964, as emended, or any other state or federal law or regulation), equitable law, or otherwise, with exception of claims arising under the National Labor Relations Act which are brought before the National Labor Relations Board, claims for medical and disability benefits under the Pennsylvania Workers' Compensation Act. Pennsylvania Unemployment Compensation claims, or as otherwise required by state or federal law. However, nothing herein shall prevent me from filing and pursuing proceedings before the Pennsylvania Human Relations Commission, or the United States Equal Employment Opportunity Commission (although if I choose to pursue a claim following the exhaustion of such administrative remedies, that claim would be subject to the provisions of this Agreement.) Further, this Agreement shall not prevent either me or the Company from obtaining provisional remedies to the extent permitted by Pennsylvania law (either before the commencement of or during the arbitration process), pending final resolution of the dispute pursuant to this Agreement. In addition to any other requirements imposed by law, the arbitrator selected shall be a retired Pennsylvania Commonwealth Court Judge, or otherwise qualified individual to whom the parties mutually agree, and shall be subject to disqualification on the same grounds as would apply to a judge of such court. All rules of pleading, all rules of evidence, all rights to resolution of the dispute by means of motions for summary judgement and judgement on the pleadings, shall apply and be observed. Resolution of the dispute shall be based solely upon the law governing the claims and defenses pleaded, and the arbitrator may not invoke any basis (including but not limited to, notions of "just cause") other than such controlling law. The arbitrator shall have the immunity of a judicial officer from civil liability when acting in the capacity of an arbitrator, which immunity supplements any other existing immunity. Likewise, all communications during or in connection with the arbitration proceedings are privileged. As reasonably required to allow full use and benefit of this agreement's modifications to the Act's procedures, the arbitrator shall extend the times set by the Act for the giving of notices and setting of hearings. Awards shall include the arbitrators written reasoned opinion. I understand and agree to this binding arbitration provision, and both I and the Company give up our right to trial by jury of any claim I or the Company may have against each other. If hired, I agree as follows: My employment and compensation is terminable at-will, is for no definite period, and my employment and compensation may be terminated by either the Company (employer) or me at any time and for any reason whatsoever, with or without good cause. This is the entire agreement between the Company and me regarding dispute resolution, the length of my employment, and the reasons for termination of employment and this agreement supersedes any and all prior agreements regarding these issues. It is further agreed and understood that any agreement contrary to the foregoing must be entered into, in writing, by myself and the President of the Company. No supervisor or representative of the Company, other than its President, has any authority to enter into any agreement for employment for any specified period of time or make any agreement contrary to the foregoing. Oral representations made before or after you are hired to not alter this Agreement. If any term or provision, or portion of this Agreement is declared void or unenforceable it shall be severed and the remainder of this Agreement shall be enforceable. If you have any questions regarding this statement, please ask a Company representative before signing. I hereby acknowledge that I have read the above statements and understand the same. I HAVE READ THE ABOVE STATEMENT AND AGREEMENT. I CERTIFY THAT ALL OF THE INFORMATION THAT I HAVE PROVIDED ON THIS APPLICATION IS TRUE AND ACCURATE. This application will be considered active for a maximum of thirty (30) days. If you wish to be considered for employment after that time you must reapply.