Bell Socialization Services, Inc.
160 South George Stree
York, PA 17401-1408
October 21, 2019

Application for employment

Personal information (All fields required)



**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.

YES NO

YES NO

YES NO

Please note: Some MR and MH positions within the Agency require having a valid license for 2 years.

YES NO

YES NO

YES NO

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

Full time Part time On call

YES NO YES NO

YES NO

YES NO

EducationName and location of school# of years attendedDid you graduate? Yes/NoMajor/degree received
High school
College
Trade, business or correspondence school



YES NO YES NO

Former employers (List below last four employers, starting with the most recent)
Date, month and yearName and address of employerPhone numberSalaryPositionReason for leaving
From:
To:
From:
To:
From:
To:
From:
To:

Referred by

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)
NameE-mail addressPhone no.BusinessHow do you know this person?
1.
2.
3.

Physical record YES NO

In case of emergency notify

How Did You Hear About Bell Socialization?

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.








Equal opportunity employer