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Home
Contact
Make a Payment
Donate
Pay It Forward
Newsletter
Our Senior Centers
Kingwood
Newburg
North Preston
Rowlesburg
Terra Alta
Tunnelton
Valley District
In-Home Services
Services
Medicaid Waiver
Personal Care
Private Pay Program
Case Management
Veterans Program
Respite Program
Alzheimer’s/Dementia Program
Lighthouse Program
Staff
Payment Options
Careers
Contact In-Home Services
Nutrition
Menu
Nutrition Transportation
Why Nutrition is Important
Do I Qualify for Home Delivery?
Why It Is Important to Eat with Us
Transportation
Services
SHIP Counseling
Senior Employment Program
Medical Equipment Loan Closet
Medical Escort
Health Screenings
Low Income Energy Assistance
Farmers Market Coupons
Activities
At the Centers
Community Shopping
Trips and Events
Senior Clubs
Preston County Picnics
Exercises
Assist Us
Volunteer
Teach a Class
Fundraiser
Donate
Pay It Forward
About
Mission and Funding Statement
Advocacy
Staff
Newsletter
Updates
WV Senior Needs Survey
PCSC Careers
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Employment Application
Step
1
of
4
25%
PRESTON COUNTY SENIOR CITIZENS, INC.
PLEASE READ THE FOLLOWING BEFORE COMPLETING OUR APPLICATION BLANK:
1. There is no guarantee of a job offer or a job interview in completing our application blank. Your application blank will be considered with others who have submitted applications and decisions about interviews will be based on this comparison.
2. Our application blank must be completely filled out in order for it to be considered for employment.
3. If the information provided on our application cannot be satisfactorily verified by employment reference checks your application could be considered as incomplete.
4. Applications are filed according to job title. Be as specific as possible in stating the job applying for: ANY position is not an acceptable response on our application blank.
5. Due to the large number of applications we receive and the competitive nature of our employment process specific reasons for employment decisions will not be released.
6. In completing our application blank you will be subject to the following checks:
EMPLOYMENT REFERENCE CHECK FROM FORMER EMPLOYERS
CRIMINAL RECORD CHECK
DRUG SCREEN
I have read the above statements. Name of Applicant:
*
First
Last
FEDERAL AND STATE LAWS PROHIBIT DISCRIMINATION IN EMPLOYMENT BECAUSE OF SEX, AGE, RACE, COLOR, RELIGIOUS CREED,MARITAL STATUS, NATIONAL ORIGIN, ANCESTRY, CITIZENSHIP, LIABILITY FOR SERVICE IN THE ARMED FORCES OF THE UNITED STATES OR DISABILTIY OR ANY OTHER PROTECTED CLASSIFICATION.
Date
*
MM slash DD slash YYYY
Personal Information:
Email
*
Phone
*
Name
*
First
Middle
Last
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Have you ever worked under another name?
*
Yes
No
If Yes, What Name or Names?
Have you ever worked for At Home, INC. before?
*
Yes
No
If Yes, dates of employment and reason for leaving?
Are you 18 years of age or older?
*
Yes
No
Are you either a U.S. Citizen or an alien who has the legal right to remain and work in the U.S.?
*
Yes
No
(You will be required to furnish proof of lawful work status if you are extended a job offer.)
Have you ever been convicted of a crime?
*
Yes
No
If so, please describe fully the criminal conviction(s), listing the nature of the offense, the date of the offense, and your rehabilitation since the conviction(s)
(A conviction record will not necessarily be a bar to employment.)
Employment desired:
Position(s) Applied for:
*
Date you can start:
*
MM slash DD slash YYYY
Employment Availability:
*
Full Time
Part Time
Employment Availability Time:
*
7am-3pm
3pm-11pm
11pm-7am
What are your employment intentions:
*
Less Than 1 Year
1-2 Years
Indefinitely
School Information
High School
Name
Years Attended
Course of Study
Degree/Diploma
College
Name
Years Attended
Course of Study
Degree/Diploma
Other Schools
Name
Years Attended
Course of Study
Degree/Diploma
Employment History
List below your work experience (starting with your present or most recent employer) for the last five years or your last three employers, whichever will provide us with the greatest information about you.
Employment 1
Dates of Employment:
Name & Address of Employer:
Name of Supervisor:
Job Title:
Salary (Start & Finish):
Type of Business:
Briefly describe your job duties and work experience and reason for leaving:
Employment 2
Dates of Employment:
Name & Address of Employer:
Name of Supervisor:
Job Title:
Salary (Start & Finish):
Type of Business:
Briefly describe your job duties and work experience and reason for leaving:
Employment 3
Dates of Employment:
Name & Address of Employer:
Name of Supervisor:
Job Title:
Salary (Start & Finish):
Type of Business:
Briefly describe your job duties and work experience and reason for leaving:
Use this section if you need additional space and please account for all periods of unemployment:
May we contact your present employer at this time?
Yes
No
APPLICANT’S STATEMENT
I understand that if employed by Preston County Senior Citizen’s, I will be an employee at-will, which means that I can voluntarily end my employment or be terminated at any time for any reason or no reason at all. No statement whether written or oral, by any Company representative other that a written statement signed by the Director may vary the foregoing. I give the Company permission to contact all or any of my previous employers and references and authorize them to provide all information requested of them by the Company. After a tentative offer of employment has been made, if requested by the Company, I agree to take a job-related medical examination at no personal expense and authorize the examining physician to disclose the findings to the Company. I understand that any offer of employment is conditioned upon receipt of satisfactory references and satisfactory completion of such job-related medical examination. I have provided truthful and complete responses to all inquiries in the application and understand that the discovery of any falsification or omission constitutes a ground for immediate dismissal. If employed, I will abide by Company’s rules and regulations, which I understand are subject to change by the Company.
Signature:
*
First
Last
Date
*
MM slash DD slash YYYY
Professional and Character References (Other Than Relatives):
*
Name
Address
Phone Number
Professional and Character References (Other Than Relatives):
*
Name
Address
Phone Number
Professional and Character References (Other Than Relatives):
*
Name
Address
Phone Number
Name
*
First
Last
I AUTHORIZE INVESTIGATION OF ALL STATEMENTS CONTAINED IN THIS APPLICATION.
READ BEFORE SIGNING
I understand that Preston County Senior Citizens, Inc. (PCSC,INC.) insists that all of its employees be able to perform the essential functions of their employment as well as possess the character, integrity and general reputation for honesty that PCSC, INC. would itself represent in its dealings with customers, suppliers and employees, among others. Accordingly, PCSC, INC. insists on complete honesty. I, therefore, authorize PCSC, INC. to make whatever inquiries it deems appropriate to verify any information given in my application and/or determine my qualifications and ability to perform the job for which I am applying. I understand that my consideration for employment is contingent upon the results of this background/reference investigation, including verification of previous assignments, education, military and criminal/law records; authentication of the truth of all statements made in this application; personal and professional reference checks, including inquiries into my character, work performance, general reputation and work habits; and if necessary, to secure a credit report, investigative and otherwise concerning my credit worthiness and other information permitted by state/federal law. I EXPRESSLY HEREBY GIVE MY CONSENT FOR ALL CONTACTED PERSONS TO PROVIDE INFORMATION CONCERNING THIS APPLICATION AND I RELEASE EACH SUCH PERSON FROM LIABILITY FOR PROVIDING INFORMATION TO PRESTON COUNTY SENIOR CITIZENS, INC. I hereby certify that the information contained in this application is correct to the best of my knowledge and I understand that falsification of this application in any detail, including misrepresentation or omission of facts, is grounds for disqualification from further consideration, or for dismissal from employment at a later date. Futhermore, I agree to conform to the rules and regulations of PCSC, INC. and I UNDERSTAND THAT I AM APPLYING FOR A POSITION AS AN EMPLOYEE AT-WILL. I UNDERSTAND THAT, IF HIRED, MY EMPLOYMENT WILL BE FOR NO DEFINITE PERIOD OF TIME, THAT I WILL BE AN EMPLOYEE AT –WILL, THAT I WILL BE FREE TO LEAVE EMPLOYMENT WITH PCSC, INC. AT ANY TIME AND FOR ANY REASON AND THAT PCSC, INC. MAY TERMINATE MY EMPLOYMENT AT ANY TIME, WITH OR WITHOUT CAUSE AND WITH OR WITHOUT NOTICE. I UNDERSTAND THAT NOTHING IN ANY OF PCSC, INC.’S WRITTEN POLICIES, HANDBOOKS OR OTHER DOCUMENTS SHOULD BE CONTRACTUAL OBLIGATIONS ON THE PART OF PCSC, INC. FUTHERMORE, I UNDERSTAND THAT NO ONE AT PCSC, INC. IS AUTHORIZED TO MAKE ANY CONTRACT RELATING TO MY EMPLOYMENT UNLESS THE CONTRACT IS SET FORTH IN WRITING AND IS SIGNED BY THE EXECUTIVE DIRECTOR OF PRESTON COUNTY SENIOR CITIZENS, INC.
Signature
*
First
Last
Date
*
MM slash DD slash YYYY
SELF-DISCLOSURE APPLICATION AND CONSENT FORM
West Virginia Clearance for Access: Registry and Employment Screening
I, the below-named applicant, understand that this form cannot be completed until an offer of employment is made. The offer of employment is made pending the results of the investigation of registries and a fingerprint-based background check. I understand that refusal to complete Parts I, II, and III of this form constitutes my rejection of the employment offer.
I, the below-named applicant, swear/affirm, that the information contained within this application is true and correct to the best of my knowledge.
Name
First
Middle
Last
Are you addicted to alcohol, a controlled substance or a drug or are you an unlawful user thereof?
Yes
No
Have you EVER been convicted of, pled guilty or nolo contendere (no contest) to a MISDEMEANOR or FELONY IN ANY STATE OR FEDERAL COURT?
Yes
No
Have you ever been convicted of an act of violence involving a deadly weapon or an act of domestic violence?
Yes
No
Are you under indictment or do you have any criminal charges pending against you?
*
Yes
No
Are you currently serving a sentence of confinement, parole, probation or other court ordered supervision?
Yes
No
Are you the subject of a restraining order as a result of a domestic violence act or subject to a verified petition of domestic violence or subject to a protective order?
Yes
No
NOTE: If any questions 1-6 listed above are answered YES, a brief letter of explanation by the applicant must be written here. Failure to provide explanations could result in disqualification.
Consent for Investigation for Employment Purposes and Acknowledgement of Receipt of Notice
I hereby authorize the Department of Health and Human Resources (DHHR) to conduct an investigation including, but not limited to, registry and state and federal fingerprint-based background checks, into information contained in this application. I understand that my fingerprints will be retained by the West Virginia State Police for the purpose of RapBack services during my employment in a WVCARES covered provider.
Furthermore, I understand that the falsification of any information contained within this application constitutes false swearing and is an excluding act under the fitness determination process being conducted by DHHR.
I acknowledge receipt of the information contained in the Notice to All Applicants.
Name
*
First
Last
Date
*
MM slash DD slash YYYY
Name
First
Middle
Last
Gov’t Issued ID Number/Expiration:
State of Issue:
Type of ID:
Gender:
Male
Female
Height:
Weight (lbs):
Eye Color:
Brown
Blue
Hazel
Green
Gray
Red
Black
Other
Hair Color:
Brown
Blonde
Bald
Black
Gray
Red
White
Other
Social Security Number:
Date of Birth:
MM slash DD slash YYYY
Place of Birth:
City
State / Province / Region
Citizenship:
Current Mailing Address:
Street Address
County:
Current Physical Address:
Street Address
County:
List all cities and states (outside of WV) where you have lived within the past 5 years and provide approximate dates:
List all cities and states (outside of WV) where you have worked within the last 5 years and provide approximate dates:
List all names and aliases you have used formally and informally (Include maiden names, married names, nicknames, and any other name used or known as):
NOTICE TO ALL APPLICANTS
Obtaining Criminal History Report:
An individual may request of copy of his or her own criminal history report (or proof that one does not exist) for a personal review by visiting MorphoTrust at www.identogo.com or calling 1- 855-766-7746.
Appeals:
If the applicant wishes to challenge the information contained in the identity history summary, a challenge of record may be filed pursuant to W.Va. St. R. §69-10-8 with the WV State Police at http://www.wvsp.gov/Criminal%20Records/Pages/default.aspx and/or the FBI at https://www.fbi.gov/services/cjis/identity-history-summary-checks.
PRIVACY ACT STATEMENT:
Authority:
The FBI’s acquisition, preservation, and exchange of fingerprints and associated information is generally authorized under 28 U.S.C. 534. Depending on the nature of your application, supplemental authorities include Federal statutes, State statutes pursuant to Pub. L. 92-544, Presidential Executive Orders, and federal. Providing your fingerprints and associated information is voluntary; however, failure to do so may affect completion or approval of your application.
Social Security Account Number (SSAN).
Your SSAN is needed to keep records accurate because other people may have the same name and birth date. Pursuant to the Federal Privacy Act of 1974 (5 USC 552a), the requesting agency is responsible for informing you whether disclosure is mandatory or voluntary, by what statutory or other authority your SSAN is solicited, and what uses will be made of it. Executive Order 9397 also asks Federal agencies to use this number to help identify individuals in agency records.
Principal Purpose:
Certain determinations, such as employment, licensing, and security clearances, may be predicated on fingerprint-based background checks. Your fingerprints and associated information/biometrics may be provided to the employing, investigating, or otherwise responsible agency, and/or the FBI for the purpose of comparing your fingerprints to other fingerprints in the FBI’s Next Generation Identification (NGI) system or its successor systems (including civil, criminal, and latent fingerprint repositories) or other available records of the employing, investigating, or otherwise responsible agency. The FBI may retain your fingerprints and associated information/biometrics in NGI after the completion of this application and, while retained, your fingerprints may continue to be compared against other fingerprints submitted to or retained by NGI.
Routine Uses:
During the processing of this application and for as long thereafter as your fingerprints and associated information/biometrics are retained in NGI, your information may be disclosed pursuant to your consent, and may be disclosed without your consent as permitted by the Privacy Act of 1974 and all applicable Routine Uses as may be published at any time in the Federal Register, including the Routine Uses for the NGI system and the FBI’s Blanket Routine Uses. Routine uses include, but are not limited to, disclosures to: employing, governmental or authorized non-governmental agencies responsible for employment, contracting licensing, security clearances, and other suitability determinations; local, state, tribal, or federal law enforcement agencies; criminal justice agencies; and agencies responsible for national security or public safety.
Additional Information:
The requesting agency and/or the agency conducting the application-investigation will provide you additional information pertinent to the specific circumstances of this application, which may include identification of other authorities, purposes, uses, and consequences of not providing requested information. In addition, any such agency in the Federal Executive Branch has also published notice in the Federal Register describing any system(s) of records in which that agency may also maintain your records, including the authorities, purposes, and routine uses for the system(s).
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