1 Employment Application St. Mark Cathol ic Center - Roman Catholic Diocese of Erie Please print in ink. You must complete entire application and sign in ink. (Rev. 10/3/18) Applicant Information Name (first, middle, last) Address (street, city, state, zip code) Phone Number (s) Are you legally authorized to work in the United States? Yes No (If hired , you will be required to provide proof of work authorization .) Are you at least 18 years old? Yes No If not, your employment will be subjec t to verification that you meet state/federal minimum age requirements for the type of work you are applying for and have obtained a valid work permit. Have you ever applied to St. Ma rk C.C. before? Have you ever worked for St. Mark C.C. before? Yes No If yes, when: Yes No If yes, when: Under what name: Will you travel if job requires it? Yes No Will you work overtime if required? Yes No If they have b een explained, are you able to meet the attendance requirements of the position? N/A Yes No Are you able to perform the essential functions of the job for which you are applying (with or without reasonable accommodati on)? This question i s not designed to elicit information about an applicant’s disability. Please do not provide information about the existence of a disability, particular accommodation, or whether accommodation is necessary. These issues may be addressed at a later stag e to the extent permitted by law. Yes No Need more information about the job’s “essential functions” to respond. Position Applying For Part-Time or Full -Time Desired Desired Compensation Shift Preference When can you start? How were you referred to St. Ma rk C.C. ? Agency Walk -In Internet Newspaper School Friend/Relative Other Special Skills 1. If relevan t, please describe wor d processing speed, software knowledge, and office equipment experience. 2. If relevant, please describe experience using manufacturing machines and equipment. 3. Please list other valuable skills you possess that would be valuable to St. Ma rk C.C. Date ___________________ 2 Education School Name and Location (City, state) No. Years Major Subjects Diploma /Degree Received Attended High Yes No College Yes No Type Graduate Yes No Type Other (specify) Yes No Type Training Courses List an y relevant training p rograms completed. Course/Seminar Sponsoring Organization Content Date(s) Attended Required License(s) If required to drive a motor vehicle for the job applying for, state your: 1) Driver’s license number 2) state issued 3) expiration date Are you licensed/have certifications which will assist in the job? Please explain. Yes No Registration or License Number State Issued Expiration Date 3 Employment History (Start with the most recent: use separate sheet if necessary.) Name of Employer Telephone ( ) Address Job Title Employment Dates (month and year) Name of Immediate Supervisor From To Description of Duties Reason for Leaving If currently employed, may we contact as a reference? Yes No Later Name of Employer Telephone ( ) Address Job Title Employment Dates (month and year) Name of Immediate Supervisor From To Description of Duties Reason for Leaving Name of Employer Telephone ( ) Address Job Title Employment Dates (month and year) Name of Immediate Supervisor From To Description of Duties Reason for Leaving Employment References (List individuals familiar with your job qualifications (other than relatives or personal friends) Name Day Telephone ( ) Evening Telephone ( ) Address Relationship How long known? Name Day Telephone ( ) Evening Telephone ( ) Address Relationship How long known? 4 Employment References (continued) Name Day Telephone ( ) Evening Telephone ( ) Address Relationship How long known? Please R ead Carefully Before Signing This Form All information in this application is true and correct to the best of my knowledge and belief. I understand that misrepresen tations or omissions of any kind may result in denial of employme nt or be cause for subsequent dismissal if I am hired, regardless of when such information is discovered. I authorize St. Mar k C.C. to investigate my response s on this application and contact any or all of my former employers or any individuals familiar with me or my employment background for the purpose of verifying any information I have provided and/or for the purpose of obtaining any information, whether favorable or unfavorable, about me or my employment. I voluntarily and knowin gly fully re lease and hold harmless any person or organizations providing information pertaining to me or my employment. I understand that upon receiving a job offer, a physical examination and drug screening may be required. (Note: If this is a job requirement, yo u will be notified.) I understand that this application rem ains curren t for only 90 days. At the concl usion of that time, if I have not heard from the employer and still wish to be considered for employment, it may be necessary for me to reapply and fil l out a new aplication. St. Mar k C. C. does not tolerate unlawful discrimination in its employm ent practices. No question on this application is used for the purpose of limiting or excluding an applicant from consideration for employment on the bas is of his or her sex, race, color, religion, national origin, citizenship, age, disability, or any other protected status under applicab le federal, state or local laws. Within the provision of the First Amendment of the U.S. Constitut ion however, we may require that due to the ministerial nature of the work to be performed, an applicant must be a practicing member of the Roman Catholic Church. I n those cases, such requirement will be clearly stated in the position description and in any related advertisem ent for the particular job opening. Harrassment of our employees is strictly prohibited, whether it is committed by a manager, coworker, subordinate or non - employee. St. Mar k C.C. takes all complaints of harrassment seriously and all complaints w ill be investigated promptly and thoroughly. Regardless of whether or not I become employed by St. Mar k C.C., I recognize that this application is not and should not be considered a contract of employment. I understand that employm ent at St. Mar k C.C. is on an at - will basis and that my employment may be terminated with or without cause, and without notice, at any time, at my option or St. Mar k C.C.’s, unless specifically provided otherwise in a written employment contract. I furth er understand that no St. Mar k C.C. employee or representative has the authority to enter into a contract regarding duration of terms and conditions of employm ent other tha n an officer o r official of St. Mar k C.C. and then only by means of a signed written document. Signature of Applicant _______________________________________________ Date ______________________ Thank you for your interest in St. Mar k C.C.
