Click the blue section names to view and complete boxes on each section of the application.
Mandatory fields are marked with *. Do not use "(" or ")" in any entry.
Personal Info      Education      Licenses      Employment
Additional Info      References      Acknowledge      Facilities     
PHI APPLICATION FOR EMPLOYMENT
Date of Application*
Facility*
Position for which applying*
PERSONAL INFORMATION
Name* Telephone*
Address*
City* State* Zip*
Email Address*
*Have you lived in other states or territories of the United States within the past 2 years? Yes No
If yes, please list and give the dates of residency. 
*Are you under 18 years of age?  (if under 18 years of age, a work permit is required) Yes No
*Are you eligible for employment in the United States?
(Proof of U.S. citizenship or immigration status will be required upon employment) 		Yes No
*Have you ever been convicted of, or pled guilty to a felony or a misdemeanor?
If yes, please list all crimes that you have been convicted of or pled guilty to and include the date of the offense. A criminal record will not necessarily disqualify an applicant for employment.
 Yes No
*Have you ever been employed by this facility or anyother PHI facility?  Yes  No
If yes, identify the facility and give dates of employment. (facilities are located on back of this application)
   
EDUCATION & TRAINING

Name and Location Did You Graduate?

Degree Earned

 Course Of Study
High School Yes
No 		Diploma
GED
College Yes
No
Other Yes
No
PROFESSIONAL LICENSURE/CERTIFICATION
All registered, licensed and certified employees must submit proof of same to employer upon employment
Type of License or Certification Issuing State or
Organization		 Number Issue Date Expiration Date
EMPLOYMENT HISTORY
Please list your job history for the past ten years or last four employers, starting with your present or most recent employer.
From (mo/yr): Employer Name:
To (mo/yr): Address:
Last Salary: Supervisor Name: Phone:
Position Held: Reason for Leaving:
Responsibilities:
From (mo/yr): Employer Name:
To (mo/yr): Address:
Last Salary: Supervisor Name: Phone:
Position Held: Reason for Leaving:
Responsibilities:
From (mo/yr): Employer Name:
To (mo/yr): Address:
Last Salary: Supervisor Name: Phone:
Position Held: Reason for Leaving:
Responsibilities:
From (mo/yr): Employer Name:
To (mo/yr): Address:
Last Salary: Supervisor Name: Phone:
Position Held: Reason for Leaving:
Responsibilities:
ADDITIONAL INFORMATION
Please describe any training or special skills you possess applicable to the position for which you are applying:.
*Are you presently employed?   Yes   No
*May we contact your present employer?   Yes   No
*Have you ever worked in a home for the aged or other health care facility before?  
Yes   No
     If yes, where:  
     What was your title?  
*Do you have relatives currently employed at this facility?   Yes   No
     If yes, in which department(s):  
*Why are you interested in working for the PHI?  
*How did you learn about employment possibilities with PHI?  
Walk-In   Advertisement   Employee Referral   Other  
*Are you interested in:?  
Full-time   Part-time  (how many hours?   / week)   Temporary  
     If temporary, please explain:  
*Are there any hours during the day when you would not be available for work at PHI?   Yes   No
     If yes, please specify:  
*Are you willing to work on weekends?   Yes   No
*What hours do you prefer to work?   Day    Evening   Night   Other  
*Have you ever been discharged or forced to resign from any place of employment?   Yes   No
     If yes, give details:  
*Have you ever been discharged from any place of employment or subject to disciplinary action due to abuse of residents or clients?   Yes   No
     If yes, give details:  
What do you consider an acceptable wage/salary for this position?   $
REFERENCES
Please list three references who are not relatives.
*Name and Occupation
Address
*Telephone No.
Years
Known
*1.








*2.








*3.








POLICY OF NON-DISCRIMINATION
PHI maintains a policy of non-discrimination for all employees and applicants in every facet of the company's operations. In compliance with federal and state laws, PHI provides equal opportunities at all levels of employment without regard to race, sex, age, color, religion, national origin, veteran status, creed, marital status, disability or sexual orientation.
APPLICANT'S CERTIFICATION & ACKNOWLEDGEMENT

·          I certify that the information contained in this application is correct to the best of my knowledge. I further understand that falsification, misrepresentation or omission of facts is sufficient cause for rejection of this application or discharge if I am later employed.

·          I understand that all statements made here are subject to verification by the PHI. I authorize and consent to any person or organization referenced in this application to furnish PHI with any and all information concerning my previous employment, education, or any other information pertaining to me upon its request. I release from all liability or responsibility all persons or organizations requesting or supplying such information. For purposes of verification, a photocopy of this authorization shall be considered an original and valid.

·          If employed, I understand that I will be an employee "at will" and either PHI or I may terminate the employment relationship at any time with or without notice. I acknowledge that any offer of employment, or my acceptance of such, may be withdrawn, with or without cause, and with or without prior notice, at any time, at the option of PHI or myself. I understand that this application and any other documents which I may receive are not contracts of employment and that no representative of PHI other than the President/CEO, Chief Operating Officer and/or Vice President-Corporate Relations has the authority to enter into any agreement for employment for any specified period of time.

·          I agree to comply with the PHI's rules, regulations and policies and acknowledge that these rules, regulations and policies may be changed, interpreted, withdrawn, or supplemented any time and without prior notice to me.

·          I represent and warrant that I have not been excluded from, or sanctioned by the federal government health care benefits program including but not limited to Medicare, Medicaid or the Federal Retired Railway Workers Benefit Program.

·         I understand that in order to safeguard the residents, the following pre-employment checks are performed at all facilities:

Ø        reference checks

Ø        criminal background check

Ø        post-offer/pre-employment substance abuse screen

Ø        post-offer/pre-employment physical

Ø        verification of licensure/certification where applicable


*I have read and fully understand the contents of this Certification and Acknowledgement

INVESTIGATIVE CONSUMER REPORT
DISCLOSURE NOTICE AND AUTHORIZATION

Thank you for your application. This Notice is to inform you that PHI may obtain an investigative consumer report (which might include information with respect to your character, general reputation, personal characteristics and/or mode of living) in connection with your employment application and/or continuing your employment. An investigative consumer report involves personal interviews with sources such as neighbors, friends, or associates as well as a criminal background check and motor vehicle report. Such a report will be used for employment purposes only.

 

Under federal law, you have a right, within a reasonable period of time after receipt of this Notice, to make a written request for the nature and scope of the investigation requested by PHI and for a summary of your rights under the Fair Credit Reporting Act.

 

The fact that PHI may obtain an investigative consumer report does not mean, and should not be construed to mean, that PHI has otherwise decided to offer you employment or continue your employment.

 

By signing this form below, you authorize PHI to obtain or cause to be obtained an investigative consumer report.

 

If hired, this authorization shall remain in effect and serve as continuing authorization for PHI to obtain investigative consumer reports at any time during your employment with PHI.

 

 

 

Signature of Applicant:

 

________________________________________________

 

Print Full Name:

 

________________________________________________

 

Social Security No.:

 

________________________________________________

 

Date:

 

________________________________________________

PHI Facilities

PHI - Administrative Office

1217 Slate Hill Road

Camp Hill, PA 17011-8034

(717) 737-9700

Kirkland Village

One Kirkland Village Circle

Bethlehem, PA 18017-3846

(610) 691-4500

The Easton Home

1022 Northampton Street

Easton, PA 18042-4292

(610) 258-7773

Westminster Woods at Huntingdon

360 Westminster Drive

Huntingdon, PA 16652-2737

(814) 643-3160

 

PHPH - Management Services Office

120 Holiday Hills Drive

PO Box 595

Holidaysburg, PA 16648-3219

(814) 695-6371

 

Mark H. Kennedy Park

108 Pine Avenue

St. Clairsville, OH 43950-9739

(740) 695-7275

The Presbyterian Home at Holidaysburg

220 Newry Street

Holidaysburg, PA 16648-1626

(814) 695-5095

Williamsport Presbyterian Home

810 Louisa Street

Williamsport, PA 17701-3098

(570) 323-2621

Forest Park Health Center

700 Walnut Bottom Road

Carlisle, PA 17013-3699

(717) 243-1032

Presbyterian Apartments, Inc.

322 North Second Street

Harrisburg, PA 17101

(717) 233-5114

 

Ware Presbyterian Village

7 East Locust Street

Oxford, PA 19363-1399

(610) 998-2400

Windy Hill Village of the Presbyterian Homes

100 Dogwood Drive

Philipsburg, PA  17701-3098

(814) 342-6090

Glen Meadows

11630 Glen Arm Road

Glen Arm MD 21057-9403

(410) 592-5310

St. Andrew's Village

1155 Indian Springs Road

Indiana, PA 15701-3494

(724) 349-4870

Westminster Village

803 North Wahneta Street

Allentown, PA 18103-2491

(610) 434-6245

Woodland Retirement Center

P.O. Box 280

Orbisonia, PA 17243-0280 (814) 447-5563

Green Ridge Village

210 Big Spring Road

Newville, PA 17241-9486

(717) 776-3192

Sycamore Manor Health Center

1445 Sycamore Road

Montoursville, PA 17754-9520

(570) 326-2037

Westminister Village

1175 McKee Road

Dover, DE 19904-2268

(302) 674-8030