Job Form

Bell Socialization Services, Inc.
160 South George Stree
York, PA 17401-1408

April 16, 2024

Application for employment

Personal information (All fields required) Last Name First Name Middle Name

Street City State Zip

Phone no. E-Mail

**You will not be denied employment solely because of a conviction record, unless the offense is related to the job for which you have applied.
*The Age Discrimination Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40 but less than 70 years old.

Have you ever been convicted of any criminal offense?** YES NO

Do you have a valid driver's license? YES NO

Have you had your license for at least 3 years from today? YES NO

Please note: Some IDD and MH positions within the Agency require having a valid license for 3 years.

Do you have a reliable transportation which you could use in the performance of a job with the agency? YES NO

Are you at least 18 years of age?* YES NO

Are you at least 21 years of age?* YES NO

(This information is used for driving and insurance purposes.)

Employment desired Full time Part time On call

Position and shift Date you can start Salary

Are you employed now? YES NO If so may we inquire of your present employer? YES NO

Have you ever been employed by Bell? YES NO Where? When?

Have you applied to Bell before? YES NO When? Position?

Education	Name and location of school	# of years attended	Did you graduate? Yes/No	Major/degree received
High school
College
Trade, business or correspondence school

General

Subjects of special study or research work

US Military or Naval Service? YES NO Rank Present membership in National Guard or Reserves? YES NO

Former employers (List below last four employers, starting with the most recent)

Date, month and year	Name and address of employer	Phone number	Salary	Position	Reason for leaving
From: To:
From: To:
From: To:
From: To:

Referred by Name Organization

Is this person a current bell employee? YES NO

References (Give the names of three work related references. If you have never worked before, give the name of three non-related people whom you have known for at least one year)

	Name	E-mail address	Phone no.	Business	How do you know this person?
1.
2.
3.

Physical record Can you perform the essential functions of the job without accommodations? YES NO

If no, what accommodations are required for you to perform the job?

In case of emergency notify Name Address Phone no.

How Did You Hear About Bell Socialization? Referred By:

I certify that the facts contained in this application are true and complete to the best of my knowledge. I understand that, if I become employed, any falsified statements on this application shall be grounds for dismissal. I hereby authorize Bell Socialization Services and its representatives to conduct an investigation of all statements contained herein. Further, I authorize the references and past employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise. By signing below, I release all parties from all liability for any damage that may result from furnishing information to Bell Socialization Services, Inc. I understand and agree that, if hired, my employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time without prior notice.

Signature (full name)

Equal opportunity employer