Berks Application For Employment Form – Fill Out and Use This PDF

COUNTY OF BERKS

Berks County Prison	Courthouse/Services Center	Berks County Home – Berks Heim	Berks County Youth Center
1287 County Welfare Road	633 Court Street	1011 Berks Road	1261 County Welfare Road
Leesport, PA 19533	Reading, PA 19601-3584	Leesport, PA 19533	Leesport, PA 19533

APPLICATION FOR EMPLOYMENT

Qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital or veteran status, sexual orientation, political affiliation, or disability.

Personal Information:

Name

Last

First

Middle

Address

Number

Street

City

State

Zip Code

Phone No.

Social Security Number

Have you filed an application here within the past two years?

Yes

No

Have you ever been employed here before?

Yes

No

Date

Are you legally eligible to work in the United States?

Yes

No

Have you ever been convicted of a felony?

Yes

No

(Conviction will not necessarily disqualify an applicant from employment)

If yes, explain

If required by the position would you be able to work:
nd rd				Yes	No
Evening hours (2 or 3 shift)?
Weekends?				Yes	No
Are you available to work overtime if asked?				Yes	No
Are you on lay-off and subject to recall?				Yes	No
Can you travel if a job requires it?				Yes	No
Some positions within the County of Berks require
a valid drivers license. Can you meet this requirement if necessary?				_____ Yes	No

Skills and Qualifications:

Describe any skills appropriate for the work you are seeking such as computer/typing skills, fluency in languages, machine operation, etc. Also include any licenses, certifications, or registrations you currently hold.

List professional, trade or business organizations to which you belong and offices held. Exclude groups which indicate race, color, religion, sex, national origin, age, marital or veteran status, sexual orientation, political affiliation, or disability.

Veterans:

Special Employment Notice to Disabled Veterans, Vietnam Era Veterans, and Individuals with Physical or Mental Disabilities

Government contractors are subject to Section 402 of the Vietnam Era veterans Readjustment Act of 1974, which requires that they take affirmative action to employ and advance in employment qualified disabled veterans and veterans of the Vietnam Era, and Section 503 of the Rehabilitation Act of 1973, as amended, which requires government contractors to take affirmative action to employ and advance in employment qualified handicapped individuals.

If you are a disabled veteran, or have a physical or mental disability, you are invited to volunteer this information. The purpose is to provide information regarding proper placement and appropriate accommodation to enable you to perform the job in a proper and safe manner. This information will be treated as confidential. Failure to provide this information will not jeopardize or adversely affect any consideration you may receive for employment.

If you wish to be identified, please sign below.

Disabled Individual

Disabled Veteran

Vietnam Era Veteran

Signed

Agreement:

If I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice, and the County of Berks reserves the same right to terminate my employment at any time, with or without cause and without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any

specified period or definite duration.(initial)

I hereby authorize the County of Berks to thoroughly investigate my references, work records, education, criminal history, and other matters related to my suitability for employment and, further, authorize my current and former employers to disclose to the company any and all letters, reports and other information pertaining to my employment with them, without giving me prior notice of such disclosure. In addition, I hereby release the County of Berks my current and former employers, and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in

any way related to such investigation or disclosure.	(initial)

I understand that if offered employment, the offer is contingent on my passing a pre-employment alcohol and drug screen and a pre-employment physical. By signing this application, I voluntarily agree to submit to a pre-employment alcohol/drug screen and pre-employment physical upon receipt of a verbal offer of employment. I understand that failure to pass the

alcohol/drug screen and/or physical will result in withdraw of the employment offer.		(initial)

I certify that the answers given herein are true and complete to the best of my knowledge.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I also understand, that if hired, I will be required to abide by all rules and regulations of the County.

Signature of Applicant			Date

AN EQUAL EMPLOYMENT OPPORTUNITY EMPLOYER M/F/V/D

Berks County complies with the Drug-Free Workplace Act of 1989

Revised 12/2005