PCCSINC Application

First Name *

Last Name *

Social Security #

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Address

Street Address *

Address Line 2

City *

State / Province / Region *

ZIP / Postal Code *

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?*

Do you have a valid driver's license?

Yes

No

Have you had a DUI in the last 10 years?*

Yes

No

Have you ever gone by a previous name or alias? (If Yes, list other name)

Have you ever been excluded from providing Medicaid Services?

Yes

No

Do you have valid auto insurace?

Yes

No

Do you have any lifting restrictions? If yes, please explain:

Have you ever been convicted of a felony?

Yes

No

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 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.*

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Consent*

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I agree to the consent below

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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:*

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Consent*

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I agree to the consent below

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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:*

PCCS Plan for the Direct Service Workforce Investment Grant Award.

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Application

Application Form

Putnam County Comprehensive Services, Inc.

Satellite Office

Headquarters