Employment Application

Application for Employment

In order that your application may be properly evaluated, it is essential that all of the questions be answered carefully and to the best of your ability. Feel free to give additional information which will enable you and the Agency to derive the greatest benefit from your application. In addition, please attach your resume and coverletter.


If you are selected for an interview, you will be notified approximatly two weeks after deadline.

Position(s) Applied For

Position 1 Title *
Position 2 Title
Position 3 Title

Applicant Information

First Name *
Middle Name
Last Name *
Address *
City *
State *
Zip *
Phone *
Email *

Current Employment Information

Are you currently employed? *
If you are offered the position, may we contact your current employer for a reference? *
If considered for employment, may we contact your past employers for a reference? *

Work Experience

Start with the present most recent job, employer. Complete all information. Do not reference resume. Please give accurate, complete full-time and part-time employment record.

Job 1

Job 1 Company Name
Job 1 Supervisor's Name
Job 1 Phone
Job 1 Address
Job 1 Employed From
Job 1 Employed To
Job 1 Job Title
Job 1 Reason for Leaving
Job 1 Description of Work Performed

Job 2

Job 2 Company Name
Job 2 Supervisor's Name
Job 2 Phone
Job 2 Address
Job 2 Employed From
Job 2 Employed To
Job 2 Job Title
Job 2 Reason for Leaving
Job 2 Description of Work Performed

Job 3

Job 3 Company Name
Job 3 Supervisor's Name
Job 3 Phone
Job 3 Address
Job 3 Employed From
Job 3 Employed To
Job 3 Job Title
Job 3 Reason for Leaving
Job 3 Description of Work Performed

Job 4

Job 4 Company Name
Job 4 Supervisor's Name
Job 4 Phone
Job 4 Address
Job 4 Employed From
Job 4 Employed To
Job 4 Job Title
Job 4 Reason for Leaving
Job 4 Description of Work Performed


Do not reference resume

High School *
High School Address
High School # Years Completed *
Did You Graduate High School *
Type of Diploma
College *
College Address
College Course of Study
College # Years Completed
Did You Graduate College *
Type of College Diploma/Degree
Graduate Studies
Graduate Studies Address
Course of Study
Graduate Studies # Years Completed
Did You Graduate
Type of Diploma/Degree
Other Address
Other Course of Study
Other # Years Completed
Did You Graduate from Other
Other Type of Diploma/Degree
Certification/Professional License
Area of:
License #
Cert./License Date Issued
Cert./License Exp. Date

General Information

Are you legally eligible to work in the United States? *
Proof of citizenship or immigration status will be required if hired.
Do you have a valid PA Commercial driver's License? *
Do you have an Act 33 clearance? *
If yes, Act 33 date issued:
Do you have an Act 34 clearance? *
If yes, Act 34 date issued:
Do you have an FBI clearance? *
If yes, FBI date issued:
If no, or older than 5 years, are you willing to apply for clearances if needed?
If not willing to apply for clearances, please explain:
Will you submit to a post offer, pre-employment physical/ TB test & drug screen? *
If not willing to get physical and drug screen, please explain:
Can you preform the essential functions of the job with or without reasonable accommodations? *
Can you travel locally, out of town, overnight and extended stay, if job requires? *
If you can't travel, please explain:
Have you ever been employed by GECAC or any of its programs? *
If yes, list program name and dates of employment:
Does a member of your immediate family work for GECAC, any of its programs, or serve on any policy making boards? *
If yes, list name and relationship:
Rate of pay expected if hired? (Annually) *


Please read carefully. If you have any questions regarding this statement, please ask a Human Resources representative before signing.
This Agency does not discriminate in hiring or employment on the basis of race, color, religion, national origin, age, disability, sexual orientation, gender identity, or on any other basis which would be in violation of any law. Any question in the application process relating to any of the foregoing is intended to secure information for use only in connection with affirmative action obligations and record keeping requirements under applicable reporting requirements.

I understand that this application will be given consideration but its receipt does not imply employment. I understand that GECAC does not guarantee employment for any specific length of time, regardless of the quality of work.

I understand that GECAC is an "At Will" employer and I understand that employment may be terminated by me or GECAC at any time, with or without cause and with or without prior notice. I understand that no one except the Vice President/ Human Resources with the approval of the Chief Executive Officer is authorized to agree to employ me for any period of time and that if any statements to the contrary have been made to me in connection with my application for employment, those statements are incorrect and not binding on GECAC. I understand that neither this document, the personnel handbook, nor any offer of employment constitutes an employment contract.

I understand that all offers of employment are considered pending and conditional until all required documents have been submitted. These documents may include, but are not limited to: documents establishing my identity and work authorization, clearances, proof of education, references, proof of driver's license and automobile insurance, health evaluation completed by a doctor selected by the agency, and a Drug Screening. The specific documents to be required will be consistent with the job description for the position with which I am being offered employment.
I understand that any offer of employment may be conditioned upon a health evaluation by a doctor selected by the agency to determine whether or not I can perform the essential functions of the job.

I certify that I have completed this application in its entirety and that all statements made by me on this application are true and complete to the best of my knowledge, and that I have withheld nothing that would, if disclosed, affect this application unfavorably. It is understood that misrepresentation or false information given in this application in any part or given in an interview may result in the cancellation of this application and, if I am already employed, may result in termination of my employment regardless of when discovered.

I understand, also, that if employed, I am required to abide by all rules, regulations, procedures and policies of GECAC.

"Agency" as used herein means the Greater erie Community Action Committee (GECAC) to which you are applying.

I hereby acknowledge that I have read the above statement and understand the same *

Compliance with the Greater Erie Community Action Committee Drug & Alcohol Abuse/Testing Policy

As an applicant to this agency, I understand and agree that I am subject to GECAC's Drug & Alcohol Abuse/ Testing Policy. I also understand that any offer of employment by the agency may require a drug test and if so, the offer is contingent upon successfully passing a Drug Screening Test. I hereby give my consent to the agency to conduct a urinalysis for drug testing purposes.

I understand and agree that the Drug Screening Test will be performed by a laboratory selected by the agency and that the laboratory is solely responsible for the accuracy of the results of the Drug Screening Test.

I agree to execute all other consent forms required in connection with any Drug Screening Test, including any forms provided by the laboratory granting permission to take a urine specimen and release the results of my Drug Screening Test(s) to GECAC Vice President/ Human Resources.

I understand and agree that if the pre‐employment Drug Screening Test indicates a violation of the Drug Abuse Policy, the contingent job offer will be null and void.

In return for my being considered for employment, I hereby release and hold harmless GECAC, its affiliates, successors, and their officers, directors, and employees from liability whatsoever arising out of or related to any Drug Screening Test.

Refusal to sign the required consent for Drug Screening Test will be deemed refusal to take the drug test and will preclude further consideration of my application.

If you would like to review a summary of the Drug & Alcohol Abuse Policy, please ask a Human Resources representative.

*NOTE: If you are a minor (under the age of 18 years), you must have the Parental Consent and Release Form signed and dated by your parent or legal guardian and notarized. Ask a Human Resources representative for this form. The form must be returned to the GECAC Human Resource Department.

I hereby acknowledge that I have read the above statements and understand the same *

I authorize GECAC to make a thorough investigation of my personal history, including, if any, a record of law enforcement activity, my character, my education, my past employment, job activities, and general reputation.

I authorize any law enforcement agency, and previous employers or educational institutions and personal references specified by me in this application, to release to GECAC any and all information regarding my employment or scholastic standing together with any other information, personal or otherwise, that may or may not be on their records, and I release those law enforcement agencies, employers and educational institutions from liability for any damage or injury to me arising out of the release of information.

I hereby acknowledge that I have read the statement above and understand the same *

Authorization To Conduct Reference Checks And To Release Information

I hereby give my consent to Greater Erie Action Committee or the bearer hereof to conduct reference/ background checks on my previous or current employment, schooling, volunteer work and the like. Additionally, any corporation, college, school, organization, person or other party is hereby authorized and directed to furnish to Greater Erie Action Committee or the bearer hereof any and all information, records and correspondence which it may have in its possession or within its knowledge with respect to my employment, character, qualifications, performance, wages, earnings, income, compensation, school and college records or any other information relating thereto. I hereby release said companies, colleges, schools, persons or other parties from any and all liability for any damage or injury to me arising out of the release of such information.

A reproduced copy of this Authorization shall be as valid as the original.

Any exceptions to the above are noted below.  I do not give my permission to check with the following people or organizations for references:

Do not contact person #1
Do not contact person #2
Do not contact person #3
Do not contact person #4
I hereby authorize Greater Erie Community Action Committee to conduct reference checks *
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