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.