Application
For Employment

Keystone Blind Association
1230 Stambaugh Ave.
Sharon, PA 16146
(724)347-5501 / (800)837-4122

AN EQUAL OPPORTUNITY EMPLOYER

We consider applicants for all positions without regard to race, color, religion, sex, national origin, age, marital or Veteran status, the presence of a non-job-related medical condition or handicap, or any other legally protected status. Disabled persons are strongly urged to apply.

Date of application:
Position(s) applied for:
Referral Souce:
If other is selected above, please explain:
Full Name:
Mailing Address:
City:
State:
Zip Code:
Telephone:
Email Address:
If under 18, can you furnish a work permit?
Have you filed an application here before?
If yes, give date:
Have you been employed here before?
If yes, give date:
Are you employed now?
May we contact your present employer?

In accordance with the Federal Immigration and Reform Act of 1986, if you are employed by our Company, you will be asked to provide documentation that verifies your legal right to work in the United States. If you cannot provide acceptable documentation, we cannot legally employ you.

Can you provide such documentation upon employment?
On what date would you be available for work?
Are you on lay-off and subject to recall?
Can you travel if a job requires it?
Have you ever been convicted of a felony?
If yes, please explain below. Conviction does not automatically exclude you from consideration for employment:
Do you have adequate transportation to and from work?
Veteran of the U.S. Military service?
If yes, what Branch?
Have you ever been terminated or asked to resign from any job?
If yes, please explain circumstances below:
Consistent attendance and punctuality are essential requirements of every job with the Company. Is there anything which would interfere with your regular attendance and punctuality if you are offered a job with this company?
If yes, please explain below:
What foreign languages do you speak fluently?
What foreign Languages do you read fluently?
What foreign languages do you write fluently?
List Professional, trade, business, or civic activities and offices held. ( You may exclude memberships which would reveal sex, race, religion, national origin, age, ancestry,handicap or other protected status):

Professional References. List people who know your work. Do not include personal references.

Professional References 1:
Name:
Relationship:
Address:
Home/Work Telephone:
Professional References 2:
Name:
Relationship:
Address:
Home/Work Telephone:
Professional References 3:
Name:
Relationship:
Address:
Home/Work Telephone:

Because Keystone Blind Association is an employer that focuses on and targets the employment of the disabled, responding to the following questions, if appropriate, would be appreciated.

Special Employment Notice to Disabled Veterans, Vietnam Era Veterans and Individuals with Physical or Mental Handicaps:

Government contracts are subject to 38 USC 2012 of the Vietnam Era Veterans Readjustment Acts of 1974 which requires that they take affirmative action to employ and advance in employment qualified disabled veterans of the Vietnam Era, and Section 503 of the Rehabilitation Act of 1973, as amended, which requires government contractors to take affirmative action to employ and advance in employment qualified handicapped individuals

If you are a disabled veteran, or have a disability, you are invited to volunteer this information which will be treated as confidential. Failure to provide this information will not jeopardize or adversely affect your consideration for employment. KBA grants a higher status to handicapped/disabled persons for employment purposes.

If you wish to be identified, please indicate and initial below:

Initials:   
Nature of handicap/disability:

Employment Experience

Start with your present or last job. Include military service assignments and volunteer activities. You may exclude organization names which indicate race, color, religion, gender, national origin, or other protected status.

Employer 1:
Employer Name:
Employer Address:
Job Title:
Supervisor:
Dates Employed:
From:  To: 
Hourly Rate/Salary:
From:  To: 
Work Performed:
Reason for leaving:
Employer 2:
Employer Name:
Employer Address:
Job Title:
Supervisor:
Dates Employed:
From:  To: 
Hourly Rate/Salary:
From:  To: 
Work Performed:
Reason for leaving:

Employer 3:
Employer Name:
Employer Address:
Job Title:
Supervisor:
Dates Employed:
From:  To: 
Hourly Rate/Salary:
From:  To: 
Work Performed:
Reason for leaving:
Special Skills and Qualifications

Summarize special skills and qualifications acquired from employment or other experience below:
Education
High School:
School Name:
Years Completed:
Diploma / Degree:
Course of Study or Major:
Describe Specialized Training, Experience, Skills and Extra-Curricular Activities:
College or University:
School Name:
Years Completed:
Diploma / Degree:
Course of Study or Major:
Describe Specialized Training, Experience, Skills and Extra-Curricular Activities:
Graduate/Professional:
School Name:
Years Completed:
Diploma / Degree:
Course of Study or Major:
Describe Specialized Training, Experience, Skills and Extra-Curricular Activities:
Trade or Correspondence:
School Name:
Years Completed:
Diploma / Degree:
Course of Study or Major:
Describe Specialized Training, Experience, Skills and Extra-Curricular Activities:
Other:
School Name:
Years Completed:
Diploma / Degree:
Course of Study or Major:
Describe Specialized Training, Experience, Skills and Extra-Curricular Activities:
Honors Received

State any additional information you feel may be helpful to us in considering your application:

Application Agreement & Understanding

Please read carefully before initialing or submitting this form.


All information contained in this application or any other documents filled out in connection with my employment and in any interview are true and correct to the best of my knowledge and belief. I have withheld nothing that would, if disclosed, affect this application unfavorably. I understand that misrepresentations, deceptions, false statements or omissions of any kind may result in denial of employment or be cause for subsequent termination of employment if I am hired regardless of when such information is discovered.

I hereby authorize the Company to thoroughly investigate my background, references, employment record and other matters related to my suitability for employment. I authorize persons, schools, current employer (if applicable), and previous employers, their agents, employees and representatives as well as individuals and organizations contacted by the Company to provide relevant information regarding my current and/or previous employment. I hereby fully waive my rights and release all persons, schools and employers, etc. of any and all claims for providing such information.

I understand that should an employment offer be extended to me and accepted that I will fully adhere to the policies, rules and regulations of employment of the Company. I understand that this application is not and should not be considered a contract of employment. I further understand that employment at the Company is on an at-will basis and that my employment may be terminated with or without cause, and without notice, at any time, at my option or the Company’s, unless specifically provided otherwise in a written contract. I further understand that no company employee or representative has the authority to enter into a contract regarding duration or terms and conditions of employment other than an officer or official of the company, and then only by means of a signed written document.

By clicking the "Submit Application" button below I acknowledge that I have read the above statements and understand each and all of the statements and hereby grant permission to confirm the information supplied on this application by me. This application is complete and accurate to the best of my knowledge.