PCCS Masks Up!
PCCS SAFER AT HOME
11/16/2020 – 01/18/2021
Serving Hoosiers with disabilities since 1968.
Contact Us: (765) 653-9763
Putnam County Comprehensive Services Inc.
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EMPLOYMENT APPLICATION
‘*’ indicates required fields.
First Name
Last Name
Address 1
Address 2
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ZIP / Postal Code
Phone Number
E-Mail Address
Were you referred by someone? If so, whom?
Position Applied For
Expected Pay
Shifts Preferred
1st Shift
2nd Shift
3rd Shift
Any Shift
Would you accept full-time?
Yes
No
Would you accept part-time?
Yes
No
What date would you be available for work?
Have you ever been employed here before?
Yes
No
If 'Yes', please explain:
Please list any special skills or training (language, machine operation, etc.) that would be of special benefit in the job for which you are applying:
Educational Background
List the names of the schools you have attended and your course of study:
Can we contact your current employer?
Yes
No
Employer Reference 1: list your previous employer's name, contact information, the job you held, your ending salary, and your reason for leaving.
Employer Reference 2: list your previous employer's name, contact information, the job you held, your ending salary, and your reason for leaving.
Employer Reference 3: list your previous employer's name, contact information, the job you held, your ending salary, and your reason for leaving.
Personal Reference 1: list the name and contact information of your reference.
Personal Reference 2: list the name and contact information of your reference.
Personal Reference 3: list the name and contact information of your reference.
By typing your name and date below you are agreeing to the following statement: To the best of my knowledge the information contained on this application is true. I understand that nothing contained in this employment application or in the granting of an interview is intended to create a contract between me and this company for either employment or the provision of benefits and further understanding that if an employment relationship subsequently is established, I will have the right to terminate my employment at any time and the company will have a similar right. In addition, I understand that no promise, representation or agreement contrary to the forgoing is binding on the company unless it is made in writing and signed by me and an authorized representative of the company.
Name and Date:
By typing your name and date below you are agreeing to the following statement: I understand that I am applying for a position to work at Putnam County Comprehensive Service, Inc. and acknowledge that the burden of providing my qualifications is at all times upon myself. I further understand that an investigation of my background, character, and work history will be completed prior to employment. This authorization is given freely and voluntarily waiving my any disclosure of information under the Privacy Act.
Name and Date:
SUBMIT MY APPLICATION