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.
Name
*
First
Last
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Phone
*
Email
*
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?
*
Date Format: MM slash DD slash YYYY
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:
List the namaes 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.
*
Consent
*
I agree to the consent below
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:
*
Consent
*
I agree to the consent below
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:
*