Regional Services Corporation, Inc.
1 Buena Vista Circle
Lewistown, PA 17044

EMPLOYMENT APPLICATION

EQUAL OPPORTUNITY EMPLOYER - It is our policy to provide equal employment opportunities to all qualified persons
without regard to race, age, color, sex, religion, national origin, or disability.

PLEASE COMPLETE BOTH SIDES                                                       POSITION APPLIED FOR:___________

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LASTNAME                                                           FIRSTNAME                                                MIDDLE INITIAL

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MAILING ADDRESS CITY COUNTY STATE ZIPCODE

_______________ ARE YOU A U.S. CITIZEN OR OTHERWISE AUTHORIZED TO WORK IN
TELEPHONE THE U.S. ON AN UNRESTRICTED BASIS? YES NO

HOW DID YOU LEARN OF THIS OPENING?        _________________________________________________
DO YOU HAVE A PA. DRIVERS LICENSE?                                    YES                                   NO
ARE YOU OVER 18 YEARS OLD?                                   YES                            NO
HAVE YOU EVER BEEN REFUSED A BOND?    ___       YES                             NO
HAVE YOU EVER BEEN CONVICTED OF A FELONY?           YES                          NO
IF YES, DESCRIBE CONDITIONS___                                                                       _____________________

EDUCATION:

HIGHEST GRADE OF SCHOOLING: 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10 - 11 – 12 COLLEGE: 1-2 -3 -4 -5 P.G.

NAME AND LOCATION OF EDUCATIONAL INSTITUTION:

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HIGH SCHOOL DIPLOMA/DEGREE MAJOR SUB/COURSES

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COLLEGE/UNIVERSITY SEM CREDITS DIPLOMA/DEGREE MAJOR SUB/COURSES

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GRADUATE/PROFESSIONAL SEM. CREDITS DIPLOMA/DEGREE MAJOR SUB/COURSES

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OTHER SCHOOLING (TECHI-41CAL, CORRESPONDENCE, MILITARY, ETC.)

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OTHER SCHOOLING (TECHNICAL, CORRESPONDENCE, MILITARY, ETC.)

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LIST PROFESSIONAL ORGANIZATIONS OF WHICH YOU ARE A MEMBER AND PROFESSIONAL
LICENSES YOU HOLD WHICH ARE RELEVANT TO THE POSITION(S) YOU ARE APPLYING FOR

_________________________________________________________________________
LIST OFFICE MACHINES YOU OPERATE TYPING WPM DICTATION WPM FOREIGN LANGUAGES SPOKEN

EMPLOYMENT:

LIST YOUR COMPLETE EMPLOYMENT RECORD, INCLUDING PERIODS OF UNENPLOYMENT, STARTING WITH YOUR PRESENT POSITION AND WORKING BACKWARDS. ATTACH ADDITIONAL SHEETS, IF INEEDED. INCLUDE YOUR NAME AND SOCIAL SECURITY NUMBER ON EACH ATTACHED SHEET.

MAY WE CONTACT YOUR PRESENT EMPLOYER? ____________YES
NAME AND ADDRESS OF EMPLOYER:
________________________________________________

________________________________________________

NAME/TITLE OF SUPERVISOR: __________________________

_____________NO
DATE STARTED:           ______________________________________
STARTING SALARY:________________________________________
STARTING POSITION:        ___________________________________
DATE LEFT:                             __________________________________
SALARY ON LEAVING:          _________________________________
POSITION ON LEAVING:          ________________________________
TELEPHONE:                          __________________________________

DESCRIPTION OF DUTIES:____________________________________________________________________________________

REASON FOR LEAVING: ____________________________________________________

NAME AND ADDRESS OF EMPLOYER:

__________________________________________________________

NAME/TITLE OF SUPERVISOR: _______________________________

DATE STARTED:                                        __________________________
STARTING SALARY:                                                                              ____
STARTING POSITION:                  ________________________________
DATE LEFT:                                                                                      _______
SALARY ON LEAVING:_______________________________
POSITION ON LEAVING:         ___________________________________ TELEPHONE:                            ____________________________________

DESCRIPTION OF DUTIES: ________

REASON FOR LEAVING: ________________________________________________________

NAME AND ADDRESS OF EMPLOYER:
_______________________________________________________

_________________________________________

NAME/TITLE OF SUPERVISOR: _______________________

DATE STARTED:                                       __________________________
STARTING SALARY:                                 __________________________
STARTINGPOSITION:                 _________________________________
DATE LEFT:       ____________________________________________
SALARY ON LEAVING:           ___________________________________
POSITION ON LEAVING:        ___________________________________ TELEPHONE:                            ___________________________________

DESCRIPTION OF DUTIES: ________________________________________________________

_____________________________________________________________________

REASON FOR LEAVING: ________________________________________________________

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APPLICANT'S CERTIFICATION AND AGREEMENT

I CERTIFY THAT THE FACTS SET FORTH IN THIS APPLICATION FOR EMPLOYMENT ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT IF I AM EMPLOYED, FALSE STATEMENTS ON THLS APPLICATION SHALL BE CONSIDERED SUFFICIENT CAUSE FOR DISMISSAL. THE AGENCY IS HEREBY AUTHORIZED TO MAKE ANY INVESTIGATION OF MY PRIOR EDUCATIONAL AND WORK HISTORY.

I UNDERSTAND THAT EMPLOYMENT AT THIS AGENCY IS "AT WILL," WHICH MEANS THAT EITHER I OR THE AGENCY CAN TERMINATE THE EMPLOYMENT RELATIONSHIP AT ANY TIME, WITH OR WITHOUT PRIOR NOTICE, AND FOR ANY REASON NOT PROHIBITED BY STATUTE. ALL EMPLOYMENT IS CONTINUED ON THAT BASIS. I UNDERSTAND THAT NO SUPERVISOR, MANAGER, OR EXECUTIVE OF THE AGENCY, OTHER THAN THE EXECUTIVE DIRECTOR, HAS ANY AUTHORITY TO ALTER THE FOREGOING.

________________ _______________ ___________________

APPLICANT'S SIGNATURE DATE

RESEARCH QUESTIONNAIRE

This is a voluntary form and you are not required to complete it. Your answers will be used for research purposes and to help assure equal employment opportunities. "This information will be kept confidential and will be maintained separate from your application for employment."

NAME: (optional) _______________________________

SEX CLASSIFICATION Male □ Female □

DATE OF BIRTH: _______________________

EEO CLASSIFICATION:

             □            White (Not of Hispanic Origin)
             □            Black (Not of Hispanic Origin)
             □            Hispanic
             □            Asian or Pacific Islander
             □            American Indian or Alaskan Native
             □            Other (specify)

Are you a veteran of the Armed Forces? Yes □ No □
Are you a Viet Nam era veteran? Yes □ No □

SIGNATURE: (optional) __________________________________________