APPLICATION FOR EMPLOYMENT

Lycoming-Clinton Counties Commission for Community Action (STEP) Inc.

2138 Lincoln Street
Williamsport, PA 17701 (570) 326-0587

We consider applicants for positions without regard to race, color, religion, sex, national origin, age, marital or veteran status,
the presence of a non-job related medical condition or handicap, or any other legally protected status.
____________________________________________________________________________________________________
Position for which applied: Date of application:

P ____________________________________________________________________________________________________
E Last Name First Name Middle Initial Phone
R
S ____________________________________________________________________________________________________
O Street Address E-mail
N
A ____________________________________________________________________________________________________
L City, State, Zip

D ____________________________________________________________________________________________________
A
T Are you legally eligible for employment in the United States?  Yes  No
A (Proof of citizenship or immigration status will be required for completion of I-9 upon employment)
____________________________________________________________________________________________________
Do you have a means to regularly travel within Lycoming & Clinton Counties if a position requires?  Yes  No

E Jr./Sr. High School Undergraduate Graduate/Professional Trade/Technical

D
U
C School Name
A & Address
T
I
O
N
Years
& Completed 8 9 10 11 12 1 2 3 4 1 2 3 4 1 2 3 4
Diploma/
T Degree
R
A
I Describe
N Course
I Of
N Study
G

Describe any specialized training, apprenticeship, skills and extra-curricular activities:

____________________________________________________________________________________________________

Typing:  No  Yes WPM __________ Word Processing:  No  Yes

Equipment you can operate or special skills

 EMPLOYMENT – List below all present and past employment, starting with your most recent.
(If you need more space, please use additional paper

Dates Name of Employer Position or Title

From:
To: Street Address Describe your Duties
May we contact
E Yes  No  City State Zip
M
P Reason Telephone No.
L
O
Y Supervisor Reason for leaving
M
E
N
T Dates Name of Employer Position or Title
From:
H To: Street Address Describe your Duties
I May we contact
S
Yes  No  City State Zip
T
O
R Reason __________________ Telephone No.
Y
Supervisor Reason for leaving

Dates Name of Employer Position or Title

From:
To: Street Address Describe your Duties
May we contact
Yes  No  City State Zip

Reason Telephone No.

Supervisor Reason for leaving

VOLUNTEER EXPERIENCE
Dates Agency Position or Title
From:
To: Street Address Describe your Duties
May we contact
Yes  No  City State Zip

Reason Telephone No.

Supervisor

STEP, Inc. may contact the employers listed above unless indication is given otherwise.
 Branch of Service Describe your duties and any special training
Period of Active Duty (month & year)

Date of Final Discharge

____________________________________________________________________________________________

Professional Registration/Certification License/Certification No. State or Agency

(if applicable to position for which applied) (such as Class IV license)

Positions that require special registration or certification—Proof of above will be required upon hire.
For positions that require an Act 33 clearance, do you currently have such documentation from the Pennsylvania
Department of Public Welfare and the Pennsylvania State Police or FBI if not a PA resident?
 No  Yes If Yes, please provide a copy of your clearance with this application or proof of
applications for clearance. (Proof of application or actual clearance will be required prior
to hire.)
List professional, trade, business or civic activities and offices held.
You may exclude memberships which would reveal sex, race, religion, national origin, age, ancestry, or handicap
or other protected status:
___________________________________________________________________________________________

Please add any information you feel would be beneficial to STEP, Inc. in evaluating your application:
_

REFERENCES
Give name, address and telephone number of three references who are not related to you and are not previous
employers.
1.

2.

3.

___________________________________________________________________________________________
I certify that I have not knowingly withheld any facts or circumstances that would detrimentally affect this
applications. It is agreed that any misrepresentation by me in this application will be sufficient cause for
cancellation of an employment offer or for dismissal from service if I am employed.

I hereby authorize STEP, Inc. to contact my former employers or volunteer agencies unless otherwise indicated,
to make inquiries regarding my work record, and/or to contact listed schools for the release of records and
transcripts.

APPLICANT’S SIGNATURE: ________________________________ DATE _______________________

 This Organization
Participates in E-Verify

This SWA will provide the Social Security Admin- SWA and employers may not use E-Verify to re-
istration (SSA) and, if necessary, the Department verify current employees and may not limit or
of Homeland Security (DHS), with information influence the choice of documents presented for
from each applicant’s Form I-9 to confirm work use on the Form I-9.
authorization.
If you believe that your SWA
IMPORTANT: If the Government N O T I C E: has violated its responsibilities
cannot confirm that you are Federal law requires under this program or has
authorized to work, this SWA is all employers discriminated against you
required to provide you written to verify the identity and during the verification process
instructions and an opportunity employment eligibility based upon your national origin
to contact SSA and/or DHS before of all persons hired to work or citizenship status, please call
taking adverse action against in the United States. the Office of Special Counsel
you, including terminating your for Immigration Related Unfair
employment. Employment Practices at
1-800-255-7688 (TDD: 1-800-237-2515).

Employment Verification. Done.

For more information on E-Verify,
please contact DHS at:
1-888-464-4218
The E-Verify logo and mark are registered trademarks of Department of Homeland Security. Commercial sale of this poster is strictly prohibited. M-780 (rev. 12/2010)
 VOLUNTARY SURVEY

The completion of this survey by you is voluntary. The purpose of this survey is for STEP to gather sufficient information in order to comply
with governmental record keeping, reporting and other legal requirements.

All applicants are considered for employment without regard to race, color, religion, sex, national origin, age, marital or veteran status, non-job
related handicap, or any other legally protected status.

If you choose to volunteer the requested information, please note that this Survey will be separated from the application before the application
is reviewed. The Survey is then kept in a confidential file. This Form will not be considered a part of your application for employment.

THE INCLUSION OR EXCLUSION OF ANY DATA WILL NOT AFFECT ANY EMPLOYMENT DECISION.

NAME: YEAROF BIRTH:

How do you describe yourself? Check the two that best apply.

Female

Male

Black (Not of Hispanic origin): Persons having origins in any of the black racial groups of Africa.

Hispanic: Persons of Mexican, Puerto Rican, Cuban, Central or South American of other Spanish culture or origin, regardless of race.

White (Not of Hispanic origin): Persons having origins in any of the original peoples of Europe, North America, or the Middle East.

American Indian or Alaskan Native: Persons having origins in any of the original people of North America, and who maintain cultural
identification through tribal affiliation or community recognition.

Asian or Pacific Islander: Persons having origins in any of the original people of the Far East, Southeast Asia, the Indian subcontinent,
or the Pacific Islands. This area includes for example, China, Japan, Korea, the Philippine Islands, and Samoa.

Other (Please Specify)

Would you describe yourself as disabled? Yes No

Position for which you are applying:

Date of your application:
How did you first learn of this position opening? Please check only one!
Payroll Notice
Notice to Head Start Parents
STEP Board Member(s) or STEP staff person
County Employment Office
County Assistance Office
College Placement Office
Community Organization - Please specify:
______ Friend/Relative not from any of the above categories.
Newspaper Advertisement
Other - Please specify:

Thank You!