6 Mel Blount Drive
Claysville, PA 15323		 Phone: 724.948.2311
Fax: 724.948.2318
The Mel Blount Youth Home of PA: Employment Application

Prospective employees will receive consideration without discrimination because of race, creed, age color, sex, national origin, handicap or veteran status.
First Name:
 Middle Name:
 Last Name:
Street Address:
City:
 State:
 Zip:
Email:
 Home Telephone:
( )
Business Telephone:
( ) 		Social Security #
- -
Pay Expected
$ 		Have you ever applied for employment with us before? Yes No
If YES, when / /
Position Desired
 Applying For:
Will You Work Overtime?
Yes No 		Are You legally eligible for employment in the United States? Yes No
Date you are available to begin work?
/ / 		Other special training skills (languages, machine operations, etc.)
 

Education
School:

 Course of Study:

Name and location of school

Type of school:

Attended - State month and year:
From:
To:

School:

 Course of Study:

Name and location of school

Type of school:

Attended - State month and year:
From:
To:

School:

 Course of Study:

Name and location of school

Type of school:

Attended - State month and year:
From:
To:
 
Employment
Please give accurate, complete full-time and part-time employment record. Start with your present or most recent employer. Please complete all fields.
Company Name:

 Telephone:
Street Address:
 Employed - State month and year:
From:
To:
Name of Supervisor:
 Weekly Pay
Start:
Last:
State Job Title and Describe Your Work:

 Reason For Leaving:

Company Name:

 Telephone:
Street Address:
 Employed - State month and year:
From:
To:
Name of Supervisor:
 Weekly Pay
Start:
Last:
State Job Title and Describe Your Work:

 Reason For Leaving:

Company Name:

 Telephone:
Street Address:
 Employed - State month and year:
From:
To:
Name of Supervisor:
 Weekly Pay
Start:
Last:
State Job Title and Describe Your Work:

 Reason For Leaving:
 
Are you over 21 years of age?
Yes No 		Have you been convicted of a crime in the past ten years, excluding misdemeanors and summary offenses, which has not been annulled, expunged or sealed by a court? Yes No
If yes, state the offense, location, date and disposition:
Driver's License :
State:
Type:
Exp. Date /
Are there any days or hours you would be unable or unwilling to work? Yes No
If yes, please specify those days or hours you would be unable or unwilling to work:
Will you abide by the safety rules of this organization? Yes No Have you ever been disciplined for violating company safety rules or regulations?
Yes No
If yes, please explain:
How many days of work (or school) have you missed in the last two years?
 Would you be willing and able to report to work on time every day on a regular and consistent basis?
Yes No
If no, please explain:
Are you presently employed?
Yes No
If yes, may we contact your current employer?
Yes No 		Have you ever been fired or asked to resign from a job? Yes No
If yes, please explain: