Employment Application

Personal Info:

First Name (required)

Middle

Last Name (required)

Line 1 (required)

Line 2

City (required)

State (required)

Zip Code (required)

Email (required)

Phone (required)

Additional Info:

Do you possess a valid driver's license (required) YesNo

Which State (required)

Position Desired (required)

Are you authorized to work in the USA? (required) YesNo

Have you ever been convicted of a criminal offense? (required) YesNo

If yes, please explain:

Certify whether or not your name appears on any of the following lists:

LEIE {List of Excluded Individuals and Entities} (required) YesNo

SAM {System for Award Management} (required) YesNo

DPW's Medicheck list (required) YesNo

Education:

High School

School Name

School City

School State

Course of Study / Major

Graduated YesNo

Degree Received

College

School Name

School City

School State

Course of Study / Major

Graduated YesNo

Degree Received

Other

School Name

School City

School State

Course of Study / Major

Graduated YesNo

Degree Received

Employment History:

Company Name

Start Date

End Date

Address (Street, City, State, Zip)

Supervisor Name

Supervisor Title

Supervisor Phone

Your Title

Reason For Leaving

Description of Responsibilities

Company Name

Start Date

End Date

Address (Street, City, State, Zip)

Supervisor Name

Supervisor Title

Supervisor Phone

Your Title

Reason For Leaving

Description of Responsibilities

Company Name

Start Date

End Date

Address (Street, City, State, Zip)

Supervisor Name

Supervisor Title

Supervisor Phone

Your Title

Reason For Leaving

Description of Responsibilities

Personal References:

Name

Work Phone

Home Phone

Address (Street, City, State, Zip)

Occupation

Relationship to Applicant

Name

Work Phone

Home Phone

Address (Street, City, State, Zip)

Occupation

Relationship to Applicant

Name

Work Phone

Home Phone

Address (Street, City, State, Zip)

Occupation

Relationship to Applicant

Statement of Purpose

I certify that my application and all attachments are true and complete to the best of my knowledge. I understand that any incorrect, incomplete, or false statements or information furnished by me may, at the discretion of the NEPA Inclusive Camp, disqualify me from employment, or cause my dismissal. I hereby authorize NEPA Inclusive to make a thorough investigation of my past employment and activities. I release from liability NEPA Inclusive, former employers, or any persons supplying such information. The language in this application is not intended to create, nor is it to be misconstructed to consitute a contract of employment.

Personal Info:

Additional Info:

Education:

High School

College

Other

Employment History:

Personal References:

Statement of Purpose

See How We Can Support You!

Main Office

Lehigh Valley
Regional Office

Berks County
Regional Office

Pocono
Regional Office

Carbon County Office

Schuylkill County Regional Office,
Pottsville CollegeTown Alvernia University