777 Ferry Road
Doylestown, PA 18901
(215) 340-5118
www.pinerun.org
EMPLOYMENT APPLICATION
APPLICATION PROCEDURES: READ CAREFULLY
1.
For this application to be reviewed and processed, it must be complete, legible and filled out by the applicant him/herself. If you
are unable to complete this application form yourself, assistance is available in Human Resources.
2.
If your application is complete and you are qualified for a current open position, your application will be processed. If you are
qualified for a position that is not currently open, we will hold your application for one year. You must contact Human Resources if
you wish your application to be resubmitted for other positions in the future.
3.
If an offer of employment is extended, you will be required to show proof of identity and eligibility to work in the United States, to
successfully complete a pre-placement health screening and to receive an acceptable Criminal History Report as defined by the
Older Adults Protective Services Act as amended by PA Act 169 of 1996 and by Act 13 of 1997. For applicable positions,
licensure/certification, proof of immunizations and current CPR are also required.
PERSONAL INFORMATION (Please Print)
NAME:
(Last
PRESENT ADDRESS:
First
No.
HOME TELEPHONE #
May we call you at work?
 YES
Street
DAYTIME TELEPHONE #
 YES
If yes, list # and best time to call. (
Are you 18 years of age or older?
 NO
Middle Initial)
 NO
City
DATE OF APPLICATION
State
Zip Code
BEST TIME TO CALL:
AM/PM
Have you ever used any other first/last name?
)
AM/PM
 YES: ______________________________  NO
If under 18 can you provide a work certificate?
Are you a U.S. Citizen or otherwise eligible
for employment in the U.S.A.?
 YES  NO
 YES  NO
EMPLOYMENT DESIRED:
Title of position for which you are applying:
Availability to work: (check all that apply)
 Days
 Evenings
 Nights
 Full Time
 Part Time
 PRN
 Saturday
 Sunday
 Seasonal
 Temporary
 Other
 Rotating
 On Call
 Holidays
DO NOT ANSWER THIS QUESTION UNLESS YOU HAVE BEEN INFORMED ABOUT THE REQUIREMENTS OF THE JOB FOR
WHICH YOU ARE APPLYING:
Are you able to perform the essential job functions for this position, as outlined in the job description with or without reasonable
accommodations?  YES  NO
If reasonable accommodations would be required, please describe how you would perform the tasks and with what accommodation(s).
Qualified individuals with a disability must be able to perform the essential job functions and requirements with or without reasonable accommodations.
The accommodations will be considered upon request. Pine Run Community will not refuse to hire a disabled applicant who is capable of performing
the essential requirements of the job with reasonable accommodations.
PINE RUN COMMUNITY IS AN EQUAL OPPORTUNITY EMPLOYER AND IS COMMITTED TO THE PROHIBITION OF
DISCRIMINATION IN EMPLOYMENT PRACTICES BECAUSE OF RACE, COLOR , ANCESTRY, RELIGION, AGE, SEX,
NATIONAL ORIGIN, PHYSICAL OR MENTAL DISABILITY AND ANY OTHER CATEGORY PROTECTED BY LAW.
EMPLOYMENT INFORMATION:
If offered employment, on what date will you be available
for work:?
Have you ever applied for employment with Pine Run Community,
Doylestown Hospital, Lakeview, or any affiliates?
 YES  NO If yes, when & where?
Have you ever been interviewed by Pine Run Community,
Doylestown Hospital, Lakeview, or any affiliates?
 YES  NO If yes, when & where?
Have you ever been employed by Pine Run Community,
Doylestown Hospital, Lakeview, or any affiliates?
 YES  NO If yes, when & where?
How were you referred to Pine Run Community?
 Self
 Employee (Name) _____________________________  Ad
 Agency
 Other __________________
1. Have you resided in the state of Pennsylvania for two or more years prior to the date of this application?
 YES  NO
2. Have you ever been convicted of a crime, felony or misdermeanor, which has not been annulled, expunged or sealed by a court?
 YES  NO If yes, please explain:
3. Do you have a history of or a conviction of a violent crime?
 YES  NO If yes, please explain:
4. Have you ever been dismissed from any employment due to abuse of clients, residents or patients?
 YES  NO If yes, please explain:
EDUCATION: (Information required only if a specific educational level is a pre-requisite for the position sought)
EDUCATION
SCHOOL/CITY/STATE
MAJOR
DID YOU
GRADUATE?
COURSE OF STUDY
DIPLOMA/
DEGREE
High School/GED
College
Nursing
Other
SKILLS: (If you are unable to complete this section yourself, assistance is available in Human Resources.)
 TYPING
WPM
 COMPUTER
 OTHER (Please specify) _____________________
Please describe any specialized training, apprenticeship, trade, or skills that are related to the position for which you are applying:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
LICENSURE / CERTIFICATION: (Include Driver’s License if required for the position for which you are applying.)
TYPE
ORGANIZATION/
STATE
DATE ISSUED
EXPIRATION
DATE
ISSUED BY
LICENSE
NUMBER
EMPLOYMENT HISTORY: Provide the following information about your current and past employer or volunteer activities,
beginning with the most recent. Use additional sheets if necessary.
DATES EMPLOYED
EMPLOYER
FROM
TO
POSITION / TITLE
ADDRESS
CITY, STATE, ZIP CODE
SALARY
START
END
SUPERVISOR
TELEPHONE NUMBER
I:  RESIGNED WITH NOTICE
 QUIT
 WAS TERMINATED
 WAS LAID -OFF
 OTHER _______________________________
REASON FOR LEAVING:
YOUR RESPONSIBILITIES:
DATES EMPLOYED
EMPLOYER
FROM
TO
POSITION / TITLE
ADDRESS
CITY, STATE, ZIP CODE
SALARY
START
END
SUPERVISOR
TELEPHONE NUMBER
I:  RESIGNED WITH NOTICE
 QUIT
 WAS TERMINATED
 WAS LAID -OFF
 OTHER _______________________________
REASON FOR LEAVING:
YOUR RESPONSIBILITIES:
DATES EMPLOYED
EMPLOYER
FROM
TO
POSITION / TITLE
ADDRESS
CITY, STATE, ZIP CODE
SALARY
START
END
SUPERVISOR
TELEPHONE NUMBER
I:  RESIGNED WITH NOTICE
 QUIT
 WAS TERMINATED
 WAS LAID -OFF
 OTHER _______________________________
REASON FOR LEAVING:
YOUR RESPONSIBILITIES:
PLEASE EXPLAIN ALL PERIODS UNACCOUNTED FOR BY EMPLOYMENT: (If you are unable to complete
this section yourself, assistance is available in Human Resources.)
IN ADDITION TO THE SUPERVISORS LISTED PREVIOUSLY, PLEASE LIST ADDITIONAL WORK
RELATED REFERENCES:
NAME
How do you know this
reference?
Day Phone #
Company Title
Years
Known
1.
2.
3.
PLEASE ANSWER THE FOLLOWING QUESTION BELOW:
WHY ARE YOU INTERESTED IN EMPLOYMENT WITH PINE RUN COMMUNITY?
(If you are unable to complete this section yourself, assistance is available in Human Resources.)
APPLICATION CERTIFICATION:
I certify the statements made on this application for employment are true and correct, and I hereby grant Pine Run Community permission to
verify the information contained herein.
I understand the giving of false information or the failure to give complete information requested herein shall constitute grounds, among
others, for rejection of my application or my immediate dismissal in the event of my employment by Pine Run Community.
I agree to permit Pine Run Community to investigate all past and present employment, my educational history, including, but not limited to
criminal investigations. Furthermore, I certify that I have not been convicted of a felony or misdemeanor that would prohibit my working with
the elderly according to PA State Law. I understand my employment with Pine Run Community is contingent upon the receipt of satisfactory
references and recommendations from former employers, acceptable criminal history record and verification of employment eligibility.
In the event that I am hired, I understand that I will be required to satisfactorily complete a confidential, job-related pre-placement health
screening. I understand that Pine Run Community reserves the right for the health, safety, productivity and security of Villagers, Residents,
Clients and employees to require employees to submit to a medical or physical examination, provided such examination is job-related and
justified by business necessity. The examination shall be conducted at Pine Run’s expense and by a physician or physician’s designee approved
by Pine Run. I also understand that Pine Run reserves the right to require me to complete drug testing prior to and during my employment.
I also understand that, if hired, I may at times be required to work on other shifts or in other capacities as may be required. I understand that, if
hired, I will be required to adhere to the policies of Pine Run Community.
I understand that the granting of an interview is not intended to create an employment relationship and that this application for employment
and any other Pine Run Community documents are not contracts of employment and that any individual who is hired may voluntarily leave
employment upon proper notice and may be terminated by Pine Run Community at any time and for any reason. I also understand that no
representative of Pine Run is authorized to modify an employee’s at-will status in any way or to enter into any agreement, oral or written,
contrary to this statement, except for a written agreement signed by the Executive Director of Pine Run Community. If I am offered a position
by Pine Run Community, I agree to be photographed by Pine Run Community.
I authorize Pine Run Community to investigate all statements contained in this application, including making inquiries of former employers,
schools and references, by telephone or other means, to obtain information concerning my personal character, habits and disposition. I
hereby release Pine Run Community and any former employer, school reference or other person who may provide information to Pine Run
from any liability relating to the furnishing of such information.
APPLICANT’S SIGNATURE: ___________________________________ DATE: _________________