Date: Position(s) applying for:
Last Name: First Name: Middle Initial:
Telephone Number: Alternate Number:
Have you been a resident of Pennsylvania (without interruption) for two years preceding the date of this application? YES NO
Have you ever filed and application with this company before? YES NO - If yes, Date:
Have you ever been employed with this company before? YES NO - If yes, Date:
May we contact your present or previous employers? YES NO
Have you ever been terminated or disciplined by a previous employer for abuse or neglect? YES NO
If yes, which employer(s):
Are you prevented from lawfully becoming employed in this country because of a Visa or Immigration Status? YES NO
On what date would you be able to start work?
What hours are you available to work? DAY: EVENING: WEEKEND:
Do you have a valid driver's license? YES NO - Years of driving experience:
Quality Progressions is an Equal Employment / Affirmative Action Employee
Please include any pending certificates
Please provide complete and accurate information as it may effect your starting salary. Start with your present or most recent position. Account for any gaps in your employment history. Include job-related military service assignment and volunteer activities.
Have you ever had any job-related training in the United States Military? YES NO
Are you aware of any reason why you cannot perform the duties for this position that you are applying for? YES NO
Are there any other experiences, skills or abilities that you feel will qualify you for work with our company?
What type of hobbies or special activities interest you?
Prior Human Service Work Experiences
Please list the name and addresses of human services agencies with whom you are currently or have been previously employed.
I understand that Quality Progressions affords equal employment opportunity to applicants and employees. Quality Progressions' Affirmative Action Plan ensures all applicants and employees that it will not be discriminatory when judging each applicant as to qualifications for a position and each employee as to performance in a position as regards to race, color, religion, sex, age, national origin or disability.
I understand the information on this application is subject to verification by Quality Progressions. I hereby grant permission to Quality Progressions to contact my present or previous employers, unless otherwise indicated; and I further authorize my former employers to give any information as to my character and record, including employment dates, position, and salary. I hereby release Quality Progressions from all liability and damages related to reference inquiries as well as those individuals or companies who provide reference information. I understand that as a condition of employment, I will be required to undergo and successfully pass a screening for alcohol and or drugs; a motor vehicle driving record and criminal/child abuse clearance unless not applicable to the job position for which you applied.
I further understand that I will be required by federal law (the Immigration Reform and Control Act of 1986) to produce documents establishing both my identity and work authorization.
In the event of employment, I understand that false, incomplete or misleading information given on my application or interview(s) will result in separation of employment. I understand that acceptance of an offer of employment does not create a contractual obligation upon the employer to continue to employ me in the future. I understand, also, that I am required to abide by all rules and regulations of the agency as delineated in the Quality Progressions' Personnel Codes & Practices and other written policies and procedures.
I certify that answers were given herein and true complete to the best of my knowledge:
Signature (Initials): Date:
Please list three professional references (i.e. former/current supervisors, managers, directors) from at least 2 different places of employment. Please advise all references that they will be used in advance and confirm contact information.
Reference Name (First & Last):
Relationship (i.e.: supervisor):
Please list one personal reference
Personal Ref. Name (First & Last):
Relationship (i.e.: professor):
Thank you for taking the time to apply for a position at Quality Progressions!
If you accept an offer of employment from Quality Progressions, on your start date we will introduce you to our staff. In 2-3 sentences, include what you would like our staff to know about you (i.e.: employment experience, interests, etc.):
Philadelphia Office1339 Chestnut Street, Suite 700Philadelphia, PA. 19107
Phone: 267-765-2000Fax: 267-765-2019
Northampton Office65 E. Elizabeth Avenue, Suite 410Bethlehem, PA. 18018
Phone: 610-691-0215Fax: 610-691-0285
Quality Progressions mission is to be people-driven, committed, and progressive in our relationship to individuals with intellectual disabilities and their families.
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