Employment Application

AN EQUAL OPPORTUNITY EMPLOYER

All statements made by applicants for employment on this application form will be checked for accuracy. We offer equal employment opportunities to all persons without regard to race, color, religion, age, marital status, sex, national origin, disability, or any other legally protected status.

APPLICANT INFORMATION

PA Resident for 2+ Years? * Yes No

Are you 21 years old or older? * Yes No

Driving is an essential part of the job for which you are applying. Do you have a valid Driver's License? * Yes No In Process

Type of Employment Full Time Benefit Part Time Part Time Temporary

When are you willing to work? * Days Evenings Nights Weekends

Are you a citizen of the United States? * Yes No

If no, are you authorized to work in the U.S.? Yes No

Have you ever applied for a job with this company? Yes No

Have you ever worked for this company? Yes No

Have you ever been bonded? Yes No

Have you ever been refused a bond? Yes No

Have you ever been convicted of a felony? Yes No

Have you ever been involuntarily terminated or requested to resign from a position? Yes No

If yes, was it due to abuse of clients, or residents? Yes No

Do you have 6 months or more of volunteer or paid experience working with individuals with disabilities? * Yes No

EDUCATION

Do you have a high school diploma or GED? * Yes No

Did you graduate? * Yes No

If NO, last year completed 9 10 11 12

Did you graduate? Yes No

If NO, last year completed 1 2 3 4

Did you graduate? Yes No

MILITARY SERVICE

WORK INFORMATION

Are you employed now? * Yes No

Have you ever held a position of trust? (Handling money or confidential materials) Yes No

PREVIOUS EMPLOYMENT

May we contact your previous supervisor for a reference? Yes No

REFERENCES

Please list three personal references. No relatives or former employers; employer references are separate.

ADDITIONAL INFORMATION (SKILLS, TRAININGS, EXPERIENCE, OR QUALIFICATIONS)

JOB APPLICANTS AGREEMENT AND CERTIFICATION

“I certify that the information given by me in this application is true in all respects, and I agree that if the information given is found to be false in any way, it shall be considered sufficient cause for denial of employment or discharge. I authorize the use of any information in this application to verify my statement, and I authorize the past employers, all references, and any other persons to answer all questions asked concerning my ability, character, reputation, and previous employment record. I release all such persons from any liability or damages on account of having furnished such information.”

“I understand that nothing contained in this employment application or in the granting of an interview is intended to create an employment contract between ACADIA, Inc. and myself for either employment or for the providing of any benefit. No promises regarding employment have been made to me, and I understand that no such promise or guarantee is binding upon ACADIA, Inc. unless made in writing. If an employment relationship is established, I understand that I have the right to terminate my employment at any time and that ACADIA, Inc. retains the same right.”

“I understand that prior to being offered employment with ACADIA, Inc. I may be requested to take an employment physical examination which includes a drug test. In the event I have a disability which will affect my ability to take the test, I will so inform ACADIA, Inc. prior to the administration of the test so that a reasonable accommodation can be made. Requested accommodations may include accessible testing sites, modified testing conditions, and accessible testing formats. ACADIA, Inc. reserves the right to require medical documentation concerning the need for the accommodation.”

“I understand in compliance with federal law that all persons hired will be required to verify identity and eligibility to work in the United States. I also understand I will be required to complete the mandated employment eligibility verification form upon hire.”

“I understand that, if employed, policies and rules which are issued are not conditions of employment and that the employer may revise policies or procedures, in whole or in part, at any time.”

“I understand that this application will be kept on active file for 60 days from the date completed, after which time I would have to reapply.”