Pennsylvania Counseling Services

Application for Employment


Pennsylvania Counseling Services, Inc. is an Equal Opportunity Employer

Applicants are considered for all positions without regard to race, color, sex, religion, national origin, age, marital or veteran status, sexual preference, disability or any other legally protected status. This application will be given every consideration, but its receipt does not imply that the applicant will be employed. Each question should be answered in a complete and accurate manner. You may choose not to provide certain information that may identify a disability or other legally protected status.

This application can be filled out online or printed to be filled out by hand and mailed in with an up-to-date resume. If the form is completed online, you will be required to sign a copy of this application before hire.

The application should take 10-15 minutes to complete, but you can take as long as you'd like. An up-to-date resume is required with the application submission. Upon completion, your application will be sent to the Human Resources staff for review, and you will be able to print a copy of the filled-out application for your records.

Please complete the application in its entirety; applications that are incorrectly completed or incomplete will not be received.

When submitting the application, required fields which are not properly completed will appear with a pink background. The application will not submit until these errors are corrected. Upon submission of this application, you will receive a link to go back and view or edit the application. Please attach your resume in Word or PDF format before submitting.

Upon completion, send your application along with an up-to-date resume to:
Attn: Human Resources
Pennsylvania Counseling Services
200 North 7th Street
Lebanon, PA 17046

1

Personal Information



Date

*
Last Name
Last Name
*
First Name
First Name

MI
MI

*
Street Address
Street Address
*
City
City
*
State
State
*
ZIP
ZIP


Home Phone
Home Phone

Cell Phone
Cell Phone

*
Email Address
Email Address

Continue to next step


2

Job Details


*
Position Desired
Position Desired
*
Date Available to Start
Date Available to Start


Availability
Availability
AvailabilityAvailability
*
Desired Compensation
Desired Compensation

Do you have any schedule limitations?
Do you have any schedule limitations?
Do you have any schedule limitations?Do you have any schedule limitations?

*
If yes: Please state any times you are UNAVAILABLE for work.
If yes: Please state any times you are UNAVAILABLE for work.


Did someone refer you to this agency?
Did someone refer you to this agency?
Did someone refer you to this agency?Did someone refer you to this agency?

*
If yes: Please provide name.
If yes: Please provide name.

If yes: Is he or she an employee of this agency?
If yes: Is he or she an employee of this agency?
If yes: Is he or she an employee of this agency?If yes: Is he or she an employee of this agency?


If no: How did you find out about this position?
If no: How did you find out about this position?


Have you ever submitted an application to Pennsylvania Counseling Services, Inc.?
Have you ever submitted an application to Pennsylvania Counseling Services, Inc.?
Have you ever submitted an application to Pennsylvania Counseling Services, Inc.?Have you ever submitted an application to Pennsylvania Counseling Services, Inc.?
*
If yes: When did you apply?
If yes: When did you apply?


Have you, a family member or a close friend ever been employed by Pennsylvania Counseling Services, Inc.?
Have you, a family member or a close friend ever been employed by Pennsylvania Counseling Services, Inc.?
Have you, a family member or a close friend ever been employed by Pennsylvania Counseling Services, Inc.?Have you, a family member or a close friend ever been employed by Pennsylvania Counseling Services, Inc.?

*
If yes: Please provide name(s) and date(s).
If yes: Please provide name(s) and date(s).


If hired, you will be required to submit proof of your ability to be legally employed in this country. Will you be able to submit proof of citizenship or employment eligibility?
If hired, you will be required to submit proof of your ability to be legally employed in this country. Will you be able to submit proof of citizenship or employment eligibility?
If hired, you will be required to submit proof of your ability to be legally employed in this country. Will you be able to submit proof of citizenship or employment eligibility?If hired, you will be required to submit proof of your ability to be legally employed in this country. Will you be able to submit proof of citizenship or employment eligibility?


Some positions require a valid driver's license. Do you have a valid driver's license?
Some positions require a valid driver's license. Do you have a valid driver's license?
Some positions require a valid driver's license. Do you have a valid driver's license?Some positions require a valid driver's license. Do you have a valid driver's license?

*
If yes: State that issued
If yes: State that issued
*
Driver's License Number
Driver's License Number
*
Expiration Date
Expiration Date


Do you have a dependable vehicle for transportation if a vehicle is required?
Do you have a dependable vehicle for transportation if a vehicle is required?
Do you have a dependable vehicle for transportation if a vehicle is required?Do you have a dependable vehicle for transportation if a vehicle is required?


Do you have active car insurance?
Do you have active car insurance?
Do you have active car insurance?Do you have active car insurance?


Please answer this question if you are applying for a position that may include work related driving or for a treatment related position: Have you ever been convicted or completed ARD (or plead guilty) for any crime related to the operation of a vehicle (driving while intoxicated, speeding tickets, traffic violations, licence suspension, etc.)?
NOTE: The above response may be answered "The position I am applying for does not require driving" if that is the case. However, for all positions that may include driving for a treatment related position or any potential work related driving, please respond with a Yes or No. Please select YES if your driving record will show any traffic or driving related convictions. This includes speeding tickets, careless/reckless driving, stop sign violations, license suspensions, DUI, completed ARD, or any other traffic violation which will show on your DMV report.
(Information regarding convictions will not necessarily disqualify you for employment but will be reviewed in light of duties and responsibilies of the position being sought.)
Please answer this question if you are applying for a position that may include work related driving or for a treatment related position: Have you ever been convicted or completed ARD (or plead guilty) for any crime related to the operation of a vehicle (driving while intoxicated, speeding tickets, traffic violations, licence suspension, etc.)?
NOTE: The above response may be answered "The position I am applying for does not require driving" if that is the case. However, for all positions that may include driving for a treatment related position or any potential work related driving, please respond with a Yes or No. Please select YES if your driving record will show any traffic or driving related convictions. This includes speeding tickets, careless/reckless driving, stop sign violations, license suspensions, DUI, completed ARD, or any other traffic violation which will show on your DMV report.
(Information regarding convictions will not necessarily disqualify you for employment but will be reviewed in light of duties and responsibilies of the position being sought.)
Please answer this question if you are applying for a position that may include work related driving or for a treatment related position: Have you ever been convicted or completed ARD (or plead guilty) for any crime related to the operation of a vehicle (driving while intoxicated, speeding tickets, traffic violations, licence suspension, etc.)?
NOTE: The above response may be answered "The position I am applying for does not require driving" if that is the case. However, for all positions that may include driving for a treatment related position or any potential work related driving, please respond with a Yes or No. Please select YES if your driving record will show any traffic or driving related convictions. This includes speeding tickets, careless/reckless driving, stop sign violations, license suspensions, DUI, completed ARD, or any other traffic violation which will show on your DMV report.
(Information regarding convictions will not necessarily disqualify you for employment but will be reviewed in light of duties and responsibilies of the position being sought.)Please answer this question if you are applying for a position that may include work related driving or for a treatment related position: Have you ever been convicted or completed ARD (or plead guilty) for any crime related to the operation of a vehicle (driving while intoxicated, speeding tickets, traffic violations, licence suspension, etc.)?
NOTE: The above response may be answered "The position I am applying for does not require driving" if that is the case. However, for all positions that may include driving for a treatment related position or any potential work related driving, please respond with a Yes or No. Please select YES if your driving record will show any traffic or driving related convictions. This includes speeding tickets, careless/reckless driving, stop sign violations, license suspensions, DUI, completed ARD, or any other traffic violation which will show on your DMV report.
(Information regarding convictions will not necessarily disqualify you for employment but will be reviewed in light of duties and responsibilies of the position being sought.)

*
If Yes, please explain.characters available
If Yes, please explain.


Optional: What experiences have you had which might enhance your contribution to the treatment of clients? Recovery is seen as an asset.
characters available
Optional: What experiences have you had which might enhance your contribution to the treatment of clients? Recovery is seen as an asset.


To ensure there is not a conflict of interest, have you or any member of your immediate family ever been treated at Pennsylvania Counseling Services, Inc.?
To ensure there is not a conflict of interest, have you or any member of your immediate family ever been treated at Pennsylvania Counseling Services, Inc.?
To ensure there is not a conflict of interest, have you or any member of your immediate family ever been treated at Pennsylvania Counseling Services, Inc.?To ensure there is not a conflict of interest, have you or any member of your immediate family ever been treated at Pennsylvania Counseling Services, Inc.?

*
If yes: At which location?
If yes: At which location?

Continue to next step


3

Application Disclosure


A requirement of working with PCS is the disclosure of criminal, child abuse, and/or ethical violation history. PCS is required to verify this information from your submission of Act 33 and 34 and other clearances pursuant to employment. Conviction records may not necessarily disqualify an applicant from employment. Please complete the following information below.

  1. Criminal Record / Ethical Violations


    Have you ever been convicted, imprisoned, or placed on probation for a felony or misdemeanor?
    Have you ever been convicted, imprisoned, or placed on probation for a felony or misdemeanor?
    Have you ever been convicted, imprisoned, or placed on probation for a felony or misdemeanor?Have you ever been convicted, imprisoned, or placed on probation for a felony or misdemeanor?



    Have you ever been charged with a professional ethics violation?
    Have you ever been charged with a professional ethics violation?
    Have you ever been charged with a professional ethics violation?Have you ever been charged with a professional ethics violation?


    If you answered "Yes" to either of these questions, please explain below:
    *
    Date(s) of offense(s) or violation(s)characters available
    Date(s) of offense(s) or violation(s)

    *
    Nature of the offense(s) or violation(s)characters available
    Nature of the offense(s) or violation(s)

    *
    Name and location of courtcharacters available
    Name and location of court

    *
    Penalty imposed or disposition of casecharacters available
    Penalty imposed or disposition of case

    *
    Is there any other event or disclosure you would like to share which may impact the position you are applying for?
    characters available
    Is there any other event or disclosure you would like to share which may impact the position you are applying for?

  2. Child Abuse History


    Have you ever been named as the perpetrator of a founded or indicated child abuse report, or been convicted of any such crime as an adult?
    Have you ever been named as the perpetrator of a founded or indicated child abuse report, or been convicted of any such crime as an adult?
    Have you ever been named as the perpetrator of a founded or indicated child abuse report, or been convicted of any such crime as an adult?Have you ever been named as the perpetrator of a founded or indicated child abuse report, or been convicted of any such crime as an adult?

    *
    If yes: Please explain.    characters available
    If yes: Please explain.


  3. Attestation of Clearance

    By typing my name below, I attest that there is nothing which has occurred in my work or personal history which may result in a report of offenses, judgments, or findings of any kind in a Child Abuse History clearance procedure, or conviction or probation for a felony or misdemeanor on a Criminal Record Check or FBI Clearance. I further attest that I am not involved in any outstanding or pending legal issues or threat of litigation or lawsuit(s) which remain unresolved regarding issues which could be construed to having been barred or potentially being barred in the future from participation in any managed care panel or federal funding (Medicare, etc.) due to misconduct of any kind. I also attest that I will report any of the aforementioned issues if they arise at any time during my employment with Pennsylvania Counseling Services, Inc. I understand that a false response (above) or failure to report aforementioned issues which occur during my employment will be cause for employment termination.

    Type your name if you agree, or type "I do not agree". Signature will be required at time of interview.

    *
    Applicant's Name (please print)
    Applicant's Name (please print)

    Applicant's SignatureDate

    Company representative should indicate "did not sign" if applicant cannot attest to the above statement.


    Company Representative SignatureDate

  4. Verification

    My Signature below verifies that the information presented in this section is correct.

    ApplicantDate

    Agency WitnessDate


Attention: HR Department / Interviewer:

If an offense has been disclosed or the applicant has written "I do not agree" on the signature line of the Attestation of Clearance, please email or fax a copy of this form to (717) 272-7976 Attn: President/COO and CEO.
Written approval from the CEO or President/COO is required PRIOR TO HIRING.



Continue to next step
4

Work History


List the names of all employers, giving the most recent first. Please give the month and year for each position listed. In addition, be sure to list all health or human service providers for which you have worked. Be sure to list your direct experience with children, adolescents, and/or adults. Direct care experience is defined by the following categories: Mental Health, Mental Retardation, Education, Specialty Education, Early Intervention, Certified Day Care, Children and Youth, Drug and Alcohol, Juvenile Justice, Health Care, and Vocational Rehabilitation. Please complete in full detail in addition to your resume.

Employer 1


Employer Name
Employer Name

Hours/week
Hours/week


Street Address
Street Address

City
City

State
State

ZIP
ZIP


Phone (With area code)
Phone (With area code)

Employed From (mm/yy)
Employed From (mm/yy)

Employed To (mm/yy)
or present
Employed To (mm/yy)
or present

Starting Salary
Starting Salary

Final Salary
Final Salary


Your Position
Your Position

Supervisor Name
Supervisor Name


Reason for Leaving
Reason for Leaving


Job Dutiescharacters available
Job Duties


Employer 2


Employer Name
Employer Name

Hours/week
Hours/week


Street Address
Street Address

City
City

State
State

ZIP
ZIP


Phone (With area code)
Phone (With area code)

Employed From (mm/yy)
Employed From (mm/yy)

Employed To (mm/yy)
or present
Employed To (mm/yy)
or present

Starting Salary
Starting Salary

Final Salary
Final Salary


Your Position
Your Position

Supervisor Name
Supervisor Name


Reason for Leaving
Reason for Leaving


Job Dutiescharacters available
Job Duties


Employer 3


Employer Name
Employer Name

Hours/week
Hours/week


Street Address
Street Address

City
City

State
State

ZIP
ZIP


Phone (With area code)
Phone (With area code)

Employed From (mm/yy)
Employed From (mm/yy)

Employed To (mm/yy)
or present
Employed To (mm/yy)
or present

Starting Salary
Starting Salary

Final Salary
Final Salary


Your Position
Your Position

Supervisor Name
Supervisor Name


Reason for Leaving
Reason for Leaving


Job Dutiescharacters available
Job Duties


Verification of Work History

My signature below indicates that the above information is correct and that all the information listed on my resume regarding my employment history is correct. My signature also gives PCS permission to verify this work history with my former employers.
ONLINE APPLICANTS: Please type your name. Signature will required at time of interview.


Applicant Name
Applicant Name

Applicant SignatureDate


Continue to next step
5

Education


High School


Name of School
Name of School


Address of School
Address of School


Graduated?
Graduated?
Graduated?Graduated?

If in progress, When do you expect to graduate?
If in progress, When do you expect to graduate?


Technical School


Name of School
Name of School


Address of School
Address of School


Major
Major

Degree
Degree


Graduated?
Graduated?
Graduated?Graduated?

If in progress, When do you expect to graduate?
If in progress, When do you expect to graduate?


College


Name of School
Name of School


Street Address of School
Street Address of School


City
City

State
State

ZIP
ZIP


Country
Country


Major
Major

Degree
Degree


Graduated?
Graduated?
Graduated?Graduated?

If no: How many credits did you obtain?
If no: How many credits did you obtain?

If in progress, When do you expect to graduate?
If in progress, When do you expect to graduate?

Graduate/Professional


Name of School
Name of School


Street Address of School
Street Address of School


City
City

State
State

ZIP
ZIP


Country
Country


Major
Major

Degree
Degree


Graduated?
Graduated?
Graduated?Graduated?

If in progress, When do you expect to graduate?
If in progress, When do you expect to graduate?


Other


Name of School
Name of School


Street Address of School
Street Address of School


Major
Major

Degree
Degree


Graduated?
Graduated?
Graduated?Graduated?

If in progress, When do you expect to graduate?
If in progress, When do you expect to graduate?



Continue to next step
6

Professional Licenses and/or Certifications


(Not Applicable for Administrative Staff)


List any professional licenses
List any professional licenses


License number(s)
License number(s)


Has your professional license ever been suspended or revoked?
Has your professional license ever been suspended or revoked?
Has your professional license ever been suspended or revoked?Has your professional license ever been suspended or revoked?

*
If yes: Please explaincharacters available
If yes: Please explain



List any relevant certifications
List any relevant certifications


Continue to next step
7

Verification of Degree or Educational Credits Earned Form - Policy and Procedure


(Not Applicable for Administrative Staff)

Per our policy: All applicants hired must have their degree verified by the registrar or transcript office of the educational institution where they report having received a diploma. Your signature on this form gives PCS the right to verify all information regarding your educational and licensing status.


For Licensed Clinicians


Name of Applicant
Name of Applicant


SSN
SSN

Date of Birth
Date of Birth


License Type
License Type

State
State

License #
License #


I verify that the above information is correct. (Please Type your name. Signature will be required at the time of interview.)
I verify that the above information is correct. (Please Type your name. Signature will be required at the time of interview.)

Provision of false information will result in immediate dismissal.


For Unlicensed Clinical Staff

(Provide your highest educational degree and number of credits earned)


Name of Applicant
Name of Applicant


SSN
SSN

Date of Birth
Date of Birth


Degree
Degree

Major
Major


Number of credits earned
Number of credits earned


Year Received
Year Received

Name on transcript (if different from above)
Name on transcript (if different from above)


Educational Institution
Educational Institution

Location (City/State)
Location (City/State)


I verify that the above information is correct. (Please Type your name. Signature will be required at the time of interview.)
I verify that the above information is correct. (Please Type your name. Signature will be required at the time of interview.)

Provision of false information will result in immediate dismissal.

This section to be filled out by Pennsylvania Counseling Service's Administrative Staff:

__ Degree Verified by Registrar

Educational Institution
Educational Institution

Phone Number
Phone Number


Time and Date of Call
Time and Date of Call

Name of Institution's Representative
Name of Institution's Representative

__ Registrar unable to verify degree
__ Degree verified electronically (See attachment)

PCS Administrative Staff


Printed Name
Printed Name

Signature
Signature

Signature is Required for All Applicants

  • I certify that all answers given on this application are true and accurate.
  • I authorize an investigation, including verification, of all statements contained in this application for employment as Pennsylvania Counseling Services, Inc. deems appropriate in arriving at an employment decision.
  • I hereby understand and acknowledge that any employment relationship with this organization, with the exception of contracted employment, is of an "at will" nature. This means that the Employee may resign at any time, and the Employer may discharge the Employee at any time with or without cause. It is further understood that this "at will" employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of the organization.
  • I understand that this application shall not be active for more than 60 days. If, after that time, I have not heard from this company and wish to be reconsidered for employment, I will have to reapply.
  • In the event of employment, I understand that false, misleading or incomplete information given in my application or interview(s) may result in termination. I understand, also, that I am required to abide by all rules and regulations of the employer.

I verify that the above information is correct. (Please Type your name. Signature will be required at the time of interview.)
I verify that the above information is correct. (Please Type your name. Signature will be required at the time of interview.)
Signature of ApplicantDate

Upload your resume:

Please attach a resume in Microsoft Word or Acrobat PDF format.

Resume File:

Browse to your file, highlight it and click Open. When you see your file in the Resume field, you can hit Submit Application.


Printed from pacounseling.com on 5/18/2012