Barber National Institute Employment Application

Answer all questions completely.
An incomplete application will not be considered.

We are an affirmative action federal contractor equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, ancestry, age, sexual orientation, protected veteran status or disability.

*Applications will be on file for 30 days, after which you must reapply to be considered for employment.

Are you eligible to work in the United States?

Due to your ineligibility to work in the US we are unable to process your application.

*All applicants must be at least 18 years of age.

Do you meet this age requirement?

Due to our age requirement we are unable to process your application.

*All positions require a high school diploma or equivalent.

Do you meet this minimum requirement?

Due to our minimum education requirement we are unable to process your application

Contact Information

First Name
M.I.
Last Name
Primary Phone
Email
Verify Email

Contact Information

Address
Address 2
City
State
Zip / Postal Code

Referral Information

How did you hear about this position?

Availability

What are you interested in? (Check all that apply):

Availability

What shifts are you available? (Check all that apply):

Availability

Are there any days/times you are unavailable to work?
Please explain:

Salary Requirements

What is your minimum acceptable rate of pay?

Education

If you are offered an interview, please bring original documents as proof of your education.

High School
Start Year
End Year/Expected Graduation
Additional Education (College/Trade School/Grad School) +
School
Degree
Major
Start Year
End Year/Expected Graduation
Additional Education (College/Trade School/Grad School) +
School
Degree
Major
Start Year
End Year/Expected Graduation

Employment

Are you currently employed by us?

Employment

Were you previously employed by us?
What position did you hold with us and when?
Start Date
End Date

Employment History

Have you ever been previously employed?

No previous employment

List all present and past employment. (Begin with most recent and account for last 5 years).

Company Name
Employment Type
Avg. Hours Worked per Week
Phone Number
Address
City
State
Zip / Postal Code
Name of Supervisor
Job Title
Job Duties
Current Employee with this Employer

If you are currently an employee with this employer, enter today as the Job End Date below.

Job Start Date
Job End Date
Reason for Leaving
May we contact this employer?
Please explain:
Add Another Work Experience +
Company Name
Employment Type
Avg. Hours worked per Week
Phone Number
Address
City
State
Zip / Postal Code
Name of Supervisor
Job Title
Job Duties
Current Employee with this Employer

If you are currently an employee with this employer, enter today as the Job End Date below.

Job Start Date
Job End Date
Reason for Leaving
May we contact this employer?
Please explain:
Add Another Work Experience +
Company Name
Employment Type
Avg. Hours Worked per Week
Phone Number
Address
City
State
Zip / Postal Code
Name of Supervisor
Job Title
Job Duties
Current Employee with this Employer

If you are currently an employee with this employer, enter today as the Job End Date below.

Job Start Date
Job End Date
Reason for Leaving
May we contact this employer?
Please explain:

Additional Experience

Provide any experiences, practicums, skills or qualifications which you have that are related to the type of work for which you are applying. Please be specific.

Additional Qualifications
Additional Qualifications
Additional Qualifications
Additional Qualifications

References

List three (3) references. References should be people we may contact who know you well and can verify your work history. Do not list relatives.

Reference #1

Name
Relationship
Company
Phone
Email
Add Next Reference +

Reference #2

Name
Relationship
Company
Phone
Email
Add Next Reference +

Reference #3

Name
Relationship
Company
Phone
Email

Upload Resume/Cover Letter

Upload a .pdf or .doc file.

Upload Resume

Select file to upload

Upload Cover Letter

Select file to upload

Background Information

Have you ever been terminated or disciplined by a previous employer for abuse or neglect of clients in your care?
Please explain

Driver's License Information

Do you have a valid driver’s license?
Issuing State
Driver's License Number
Expiration Date
Have you had any traffic violations other than parking tickets within the last 3 years?
Please explain

Attestation Statement

By signing this application, I am representing that the facts set forth in the application are true and complete. I agree that any false or incomplete statement in this application shall be sufficient reason for rejection or dismissal, whenever discovered. The Institute is authorized to make an investigation of any information included in this application and to contact any of the schools, employers, government agencies or individuals noted for purposes of references or verification. I hereby release employers, schools or persons from all liability in responding to inquiries in connection with my application.

I expressly authorize the Institute at any time hereafter, either while I am employed at the Institute or after conclusion of my employment at the Institute, to supply information about my employment to any prospective employer, government agency, financial institution, or other party deemed by the Institute to have an appropriate interest in the information. I hereby expressly release the Institute from any and all liability in connection with the release of any such information.

I understand that the use of this application does not mean that there are any positions available and does not in any way obligate the Institute.

I recognize and agree that if I am offered and accept employment that there are certain criteria that will need to be met as prerequisites to the position for which I have been offered. To meet these requirements:

I must submit a favorable Act 33 Clearance (Child Abuse History Clearance) and an Act 34 Clearance (State Police Criminal Record Check) to the Barber National Institute. If I am not a resident of Pennsylvania, have not been a resident of Pennsylvania for the entire two years immediately (without interruption) proceeding employment, currently live out of state, or will be working with children; then in addition to the report from the PA State Police, a criminal history report from the Federal Bureau of Investigation must be submitted.

If I am hired in a position where I will have direct contact with children under 18 years of age, these clearances may not be more than one (1) year old and my clearances must be renewed every 60 months while employed by Barber National Institute.

After receiving completed Clearances, I must submit them to the Human Resource Office within 30 days of hire. I have 90 days from hire to submit FBI clearance results.

Failure to meet these requirements will result in my suspension or termination.

I must also satisfy medical criteria by receiving favorable Physical and T.B. test results. (Physicals and T.B. tests are agency paid).

I must also, if position requires, possess and maintain a valid driver’s license and be eligible to drive for the Agency. To establish eligibility, Motor Vehicle Reports will be requested and reviewed based on the Agency’s Fleet Safety Program.

I also recognize and agree that if I am offered and accept employment, I am not guaranteed any tenure of specific length of employment, and that my employment may be terminated at any time, with or without cause. I understand that no contract of employment exists between the employer and myself unless contained in a separate written and signed document which is expressly stated to be an employment contract. On occasion, the Institute may establish and distribute policies relating to various aspects of my employment. I recognize that these are intended for my instruction, information and guidance and do not create any specific rights on my part or obligations on the part of the Institute.

I acknowledge that the Institute has legitimate reason to be concerned with my standards of physical appearance and personal conduct since these matters can reflect upon the Institute and my fellow employees. If accepted for employment, I agree to abide by all rules, regulations, policies and instructions established by the Institute. I recognize that these may change from time to time over the course of my employment. I agree to wear personal protective equipment as required by Barber National Institute.

I also understand that the Barber National Institute is a smoke free and drug free workplace and that a drug and/or alcohol screening may be required with or without notice by the Institute at any time.

Attestation
Initials

Barber National Institute Applicant Self-Identification

READ BEFORE COMPLETING

As an employer and government contractor, we comply with government regulations, including but not limited to the Vietnam Era Veteran's Readjustment Assistance Act of 1974 (VEVRAA), the Jobs for Veterans Act of 2003, as amended where applicable, as well as all other applicable current local, state and federal Equal Employment Opportunity Statutes. Our affirmative action responsibilities include but are not limited to employing and advancing in employment qualified minorities, females, disabled individuals and veterans in protected classifications as identified below. As a federal contractor, the company is required to take affirmative action to employ and advance in employment protected veterans, minorities, females and the disabled pursuant to applicable legislation. You may provide this information at this time and/or at any time in the future. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information provided will be used only in ways that are not inconsistent with applicable current legislation. The information you submit will be kept confidential, except that (i) Supervisors and managers may be informed regarding restrictions on the work or duties of disabled individuals, and regarding necessary accommodations; (ii) First aid and safety personnel may be informed, when and to the extent appropriate, if you have a condition that might require emergency treatment; and (iii) Government officials engaged in enforcing laws administered by OFCCP, or enforcing the Americans with Disabilities Act, may be informed.

Your Name
Please check this box if you wish to participate in this survey
Select one of the following
Select one of the following (Ethnic Origin)

Veteran Status

Veteran Status (Check One) If you believe you belong to any of the categories of protected veterans listed on page 2, please indicate by checking the appropriate box below. As a government contractor subject to VEVRAA, we request this information in order to measure the effectiveness of the outreach and positive recruitment efforts we undertake pursuant to VEVRAA.

Select one of the following

Voluntary Self-Identification of Disability

Why are you being asked to complete this form?

Because we do business with the government, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities. i To help us measure how well we are doing, we are asking you to tell us if you have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will choose to fill it out. If you are applying for a job, any answer you give will be kept private and will not be used against you in any way.

If you already work for us, your answer will not be used against you in any way. Because a person may become disabled at any time, we are required to ask all of our employees to update their information every five years. You may voluntarily self-identify as having a disability on this form without fear of any punishment because you did not identify as having a disability earlier.

How do I know if I have a disability?

You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition.

Disabilities include, but are not limited to:

  • Blindness
  • Deafness
  • Cancer
  • Diabetes
  • Epilepsy
  • Autism
  • Cerebral palsy
  • HIV/AIDS
  • Schizophrenia
  • Muscular dystrophy
  • Bipolar disorder
  • Major depression
  • Multiple sclerosis (MS)
  • Missing limbs or partially missing limbs
  • Post-traumatic stress

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Today's Date