Free 08-202 Employment Application - Pennsylvania

EMPLOYMENT APPLICATION
FIRST JUDICIAL DISTRICT OF PENNSYLVANIA HUMAN RESOURCES
An Equal Opportunity Employer

OFFICE USE ONLY
POSITION

File: ACKNOWLEDGEMENT: REJECTED:
APPEAL

Test

REJECTED:
NOTICE TO TEST

(1) (2) (3)
RESULTS

Accepted: The First Judicial District of Pennsylvania does not discriminate on the basis of race, color, religion, age, sex, national origin, veteran status, mental or physical disability. Rejected: Notice Sent:

(1) (2) (3)

READ THESE INSTRUCTIONS CAREFULLY BEFORE COMPLETING THIS FORM:
1. 2. 3. 4. 5. City residency requirements will be enforced six months after completion of the orientation period of employment. If any pertinent questions are not answered, this application will be rejected. If you do not meet the minimum training and experience qualifications for the position applied for, this application will be rejected. Application must be signed to be accepted, and returned to the Courts' Human Resources Office, Room 668 City Hall, Philadelphia, PA 19107. If you intentionally make any false statements or material omissions, this application will be rejected.
ADDRESS

NAME (Last, First, Middle Initial)--indicate any former names under which you worked or are known. SOCIAL SECURITY NUMBER HOME PHONE

(City)

(State)

(Zip)

BUSINESS PHONE

POSITION APPLIED FOR

SALARY DESIRED

WERE YOU EVER EMPLOYED BY COURT SERVICE AND/OR CITY OF PHILA.?

FOREIGN LANGUAGES

SPEAK READ WRITE

No

Yes

Dates:

Dept:

RELATIVES EMPLOYED BY COURT SERVICES:

Have you ever been convicted of an offense (including military offenses) other than Have you ever been dismissed for inefficiency, delinquency, or a minor traffic violation? (Do not include convictions while a juvenile nor convictions misconduct, or been permitted to resign to avoid dismissal? sealed by Court order.) Yes No

YES

NO

If so, please state nature of offense(s), date(s), city and state, and disposition. A conviction record is not an automatic bar to employment and the nature, recency and disposition of an offense will be considered.

If yes, explain:

Please provide license, registration, or certification information required for the position you are seeking. Also indicate whether such license, registration, or certification is currently active. May we contact your present employer for information? If no, explain: Yes No

READ THIS APPLICATION AND YOUR ANSWERS CAREFULLY BEFORE SIGNING BELOW I certify that the statements made by me on BOTH SIDES of this application are true, complete and correct to the best of my knowledge and belief and are made in good faith. I understand that if I knowingly omit or make any misstatement of facts I am subject to disqualification or dismissal and to such other penalties as may be prescribed by law, ordinance, or Personnel Policies. If I am hired, I understand I am being hired as an "at will employee" of the First Judicial District of Pennsylvania. In the event that there is a need for a reduction in force, for any reason, I understand that I may be subject to lay off. I further understand that if there is a lay off I shall not be entitled to displace other court employees solely because of seniority.

Date
08-202 (Rev. 4/00)

Signature

SCHOOL (Circle highest grade completed)

(Circle full academic years of college completed)

EDUCATION

1

2

3

4

5

6

7

8

9

10

11

12

1

2

3

4

5

6
Course Credits

7

8

NAME OF SCHOOL
Elementary High School College, University or Professional School Other Training or School

CITY/STATE

SHOW D - Day N - Night

DID YOU GRADUATE
Yes No

NO. OF CREDITS REC'D
Semester or Qtr. or Hours Hours

TYPE MAJOR DEGREE COURSE REC'D STUDY

EXPERIENCE:

Describe your duties fully. If you held several different positions with the same emloyer, list each separately. Begin with the MOST RECENT employment and work backward consecutively. If you need more space, list in the same format on blank 8½ x 11 sheets.
FIRM NAME ADDRESS CITY AND STATE

LENGTH OF EMPLOYMENT From: Mo. To: Mo. Yr.

TYPE OF BUSINESS Yr.

YOUR TITLE

NAME & TITLE OF IMMEDIATE SUPERVISOR

SALARY OR WAGE Starting Final per per TOTAL HRS. PER WEEK

DUTIES: Describe the nature of the work PERSONALLY performed by you with estimated PERCENTAGE OF TIME on each type of work. State size and kind of working force, if any, supervised by you and extent of such supervision.

REASON FOR LEAVING

LENGTH OF EMPLOYMENT From: Mo. To: Mo. Yr.

FIRM NAME

ADDRESS

CITY AND STATE

TYPE OF BUSINESS Yr.

YOUR TITLE

NAME & TITLE OF IMMEDIATE SUPERVISOR

SALARY OR WAGE Starting Final per per TOTAL HRS. PER WEEK

DUTIES: Describe the nature of the work PERSONALLY performed by you with estimated PERCENTAGE OF TIME on each type of work. State size and kind of working force, if any, supervised by you and extent of such supervision.

REASON FOR LEAVING

LENGTH OF EMPLOYMENT From: Mo. To: Mo. Yr.

FIRM NAME

ADDRESS

CITY AND STATE

TYPE OF BUSINESS Yr.

YOUR TITLE

NAME & TITLE OF IMMEDIATE SUPERVISOR

SALARY OR WAGE Starting Final per per TOTAL HRS. PER WEEK

DUTIES: Describe the nature of the work PERSONALLY performed by you with estimated PERCENTAGE OF TIME on each type of work. State size and kind of working force, if any, supervised by you and extent of such supervision.

REASON FOR LEAVING

EXPERIENCE (LIST ANY ADDITIONAL WORK EXPERIENCE OR VOLUNTEER WORK - ACCOUNT FOR ALL TIME SINCE SCHOOL) DATE (Mo. & Year)
From To

NAME OF EMPLOYER

ADDRESS

YOUR TITLE

YOUR SALARY

REASON FOR LEAVING

08-202 (Rev. 4/00)

This application must be completed on both sides.

FIRST JUDICIAL DISTRICT OF PENNSYLVANIA HUMAN RESOURCES

AFFIRMATIVE ACTION QUESTIONNAIRE
Instructions: It is requested that each applicant for employment with the First Judicial District of Pennsylvania Philadelphia County provide the following information. It will be detached when your application is filed and the information on it will not be considered in the employment process.

1. Ethnic Group (please check one) a. e. 2. Sex: White Asian American a: Male b. f. b. Black Multi-Cultural Female c. g. Hispanic Other d. American Indian

To be detached by the Human Resources Department of the First Judicial District of Pennsylvania

3. Age:

Date of Birth:

4. Type of Work Desired (please indicate one preference as appropriate) a. b. c. d. e. f. Administrative Professional Technical Office/Clerical Skilled Craft Service/Maintenance

5. Applied to the First Judicial District of Pennsylvania in Response to: a. b. c. d. e. Advertisement
(Name of publication/newspaper/TV/radio station)

Pennsylvania Employment Service Community or Professional Organization or Agency Referred by a Court employee Other

************************* I certify that the above information is true and correct. (Please print legibly) Name: Address:
(Street) (Town) (State) (Apt. No.) (Zip Code)

Date:

(Signature)
08-202 (Rev. 4/00)