LAFLIN RECREATION BOARD – SUMMER CAMP COUNSELOR APPLICATION Application Deadline: May 1, 2015 APPLICANT INFORMATION Last Name First M.I. Street Address Date Apartment/Unit # City State ZIP Phone E-mail Address Cell Phone June 29th – July 31 1st {Monday, Wednesday, Friday} – 9:00 to 12:00pm Camp Dates / Time Are you legally eligible for employment in the U.S. YES NO Are you 18 years of age or older? Do you have a current PA Child Abuse History Clearance, a current PA Criminal History Record Check and a current FBI Criminal Background Check? YES NO If so, dates? Have you ever been convicted of any criminal offense? YES NO If yes, explain EDUCATION High School From To Did you graduate? YES NO Degree To Did you graduate? YES NO Degree To Did you graduate? YES NO Degree College From Other From REFERENCES Please list two references not related to you, whom you have known at least one year. Full Name Relationship Company Phone ( ) Address Full Name Relationship Company Phone Address ( ) YES NO PREVIOUS EMPLOYMENT Company Phone Address Supervisor ( ) Job Title Responsibilities From To Can Employer by Contacted? Company Phone Address Supervisor ( ) Job Title Responsibilities From To Can Employer be Contacted? DISCLAIMER AND SIGNATURE I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release. Applicants must be 18 years of age or over. This application must have attached a current: • Pennsylvania Child Abuse History Clearance (CY113) • Pennsylvania Criminal Records Check (SP4-164) • Federal Bureau of Investigations (FBI) Criminal Background Check Signature Date CHILDLINE AND ABUSE REGISTRY - PENNSYLVANIA DEPARTMENT OF HUMAN SERVICES Child Abuse History Clearance Online: https://www.compass.state.pa.us/CWIS PENNSYLVANIA STATE POLICE CRIMINAL RECORD CHECK INSTRUCTIONS Below is the link to the Pennsylvania Criminal Record Check form (SP4-164): Pennsylvania State Police Request for Criminal record Check Form (SP4-164) Applicants can also go to the Pennsylvania Access To Criminal History website and apply for their criminal record check online with the Pennsylvania State Police at: https://epatch.state.pa.us/Home.jsp If you have questions about the Pennsylvania State Police Request for Criminal Record Checks form (SP4 164), please call: (717) 783-9973 or toll free 1-888-783-7972. FEDERAL BUREAU OF INVESTIGATION (FBI) CRIMINAL BACKGROUND CHECK INSTRUCTIONS The Pennsylvania Department of Human Services is utilizing Cogent Systems to process fingerprint-based FBI criminal background checks. The fingerprint based background check is a multiple step process. For more information and to begin the registration process, go towww.pa.cogentid.com//index_dpw.htm. For question about your FBI Clearance, please contact the FBI/Adam Walsh Unit at 717-783-6211 or 1-877-371-5422.
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