APPLICATION

FOR EMPLOYMENT

HARRISBURG PARKING AUTHORITY

McCormick Public Services Center

123 Walnut Street, Suite 317

P. O. Box 1142

Harrisburg, PA 17108-1142

(PLEASE PRINT)

DATE OF HIRE:

Last Name					First Name				Middle Name
Address	Number		Street			City				State	Zip Code
Previous Address (if present address less than 5 yrs.)		Number		Street			City			State	Zip Code
Telephone Number(s)								Social Security Number ─ ─

Have you ever filed an application with us before?

¨ Yes

¨ No

If Yes, give date

List any friends or relatives working for us:

Are you currently employed?

¨ Yes

¨ No

If so, may we contact your present employer?

¨ Yes

¨ No

Date available for work

Salary Requirements

Do you have a valid Pennsylvania Driver’s License?

¨ Yes

License No.

¨ No

Have you had any moving violations during the last five years?

¨ Yes

¨ No

Have you ever been refused bonding or been cancelled under a prior bond?

¨ Yes

¨ No

Are you currently bondable?

¨ Yes

¨ No

¨ Don’t Know

EDUCATION

Name & Location of School

No. of Yrs. Attended

Did You

Graduate?

Major Course

of Study

High School

College

Trade, Business, or

Correspondence School

Please describe additional skills, training, or abilities you would like to have us consider in evaluating your qualifications:

Typing Speed (Words per Minute):

Computer/PC Experience: Yes ¨ No ¨

If yes, list the software that you have experience with:

1. Are you able, without accommodation, to perform all of the functions of the job for which you are applying?

Yes ¨ No ¨

If you answered “No” to question number 1, please answer question number 2.

2. Are you able, with reasonable accommodation, to perform all of the functions of the job for which you are

applying?

Yes ¨ No ¨

If yes, please describe the accommodation that you need:

3. Are there any functions of the job for which you are applying that you cannot perform with or without accommodation?

Yes ¨ No ¨

If yes, please describe:

FORMER EMPLOYERS (List your last three employers, starting with your current employer.)

Employer	Dates Employed		Work Performed
	From	To
Address
Job Title	Hourly Rate/Salary
	Starting	Final
Supervisor
Reason for Leaving
Employer	Dates Employed		Work Performed
	From	To
Address
Job Title	Hourly Rate/Salary
	Starting	Final
Supervisor
Reason for Leaving
Employer	Dates Employed		Work Performed
	From	To
Address
Job Title	Hourly Rate/Salary
	Starting	Final
Supervisor
Reason for Leaving

US MILITARY SERVICE

Branch

Type of Discharge

Highest Rank and Principle Duties

OTHER

Are you a United States citizen? Yes ¨ No ¨

If you are not a U.S. citizen, are you an alien lawfully authorized to work in the U.S.? Yes ¨ No ¨

Can you submit a birth certificate, other proof of U.S. citizenship or legal right to work permanently in the U.S.?

Yes ¨ No ¨

CRIMINAL PROCEEDINGS

A. Have you EVER been convicted of any Felony or Misdemeanor offenses? Yes No

B. Have you EVER pled guilty to any Felony or Misdemeanor offenses? Yes No

C. Do you currently have Felony or Misdemeanor offense charges pending? Yes No

If you answered "Yes" to any of the above questions, you must provide the following information for each offense. Use addition sheets of paper (8 1/2" X 11"), if necessary.

Offense:

Date of Offense:

City and State in which offense occurred:

Name of court having jurisdiction:

Disposition or sentence for offense:

Additional information:

Offense:

Date of Offense:

City and State in which offense occurred:

Name of court having jurisdiction:

Disposition or sentence for offense:

Additional information:

PLEASE NOTE THAT YOU MUST PROVIDE ALL REQUESTED CRIMINAL INFORMATION. BY SIGNING THIS EMPLOYMENT APPLICATION, YOU AUTHORIZE THE HARRISBURG PARKING AUTHORITY AND/OR ITS AGENTS TO PERFORM A CRIMINAL HISTORY INVESTIGATION TO VERIFY DISCLOSURE OF ALL CRIMINAL INFORMATION CONTAINED IN YOUR PUBLIC RECORD. CRIMINAL CONVICTIONS WILL NOT AUTOMATICALLY DISQUALIFY AN APPLICANT.

The Harrisburg Parking Authority is an Equal Opportunity Employer: Our policy is to abide by all Federal and State laws prohibiting employment discrimination on the basis of a person’s race, color, national origin, religion, age, sex, marital status, or physical disability.

I hereby give the Harrisburg Parking Authority the right to make a thorough investigation into my previous employment, education, criminal, driving, consumer, credit records and references; and I release from all liability all persons, companies, and corporations supplying such information. I understand that I have the right to make a written request within a reasonable period of time to receive complete information about the nature and scope of this investigation. I release, indemnify, and hold harmless the Harrisburg Parking Authority from and against any and all liability which might result from making such an investigation.

I understand that any false answer, statement, or representation made by me in this application shall constitute sufficient cause for discharge.

I also understand that nothing contained in this employment application or granting of an interview is intended to create an employment contract between the Harrisburg Parking Authority and myself for either employment or for the granting of benefits. No promises regarding employment have been made to me, and I understand that no such promise or guarantee is binding upon the Harrisburg Parking Authority unless made in writing.

If an employment relationship is established, I understand and agree that for non-bargaining unit (i.e., “non-union”) employees and probationary employees within the bargaining unit, the relationship is not for a definite period of time and that I have the right to terminate my employment at any time and that the Harrisburg Parking Authority retains a similar right. I also understand and agree that for bargaining unit employees the employment relationship is governed by the terms of the Collective Bargaining Agreement.

I understand that, if accepted for employment, it is necessary to abide by the rules and policies of the Harrisburg Parking Authority and that I will be on probation before being considered a regular employee.

Signature Date

Revised 08/18/03

Position(s) Applied For

Date of Application

Full Time ¨ Part Time ¨ Temporary ¨

How Did You Learn About The Position?

¨ Newspaper Advertisement

¨ Referred By