Employment Form Test - Diversified Family Services

NOTE: You must complete this form in it's entirety and click submit. If you do not get a confirmation saying your application was successfully submitted, you have not submitted your application.

Our company does not discriminate in employment opportunities or practices on the basis of race, color, religion, sex including sexual orientation, gender identity or status as transgender, national origin, age, disability, military service, genetic information or any other characteristic protected by federal, state, or local law.

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Date

Personal Information

Are you 19 years of age or older?

Yes

No

Name

First Middle Last Suffix

Address*

Street Address Address Line 2 City State ZIP Code

Home Phone*

Cell Phone

Optional

Email*

Do you have any relatives currently employed by this agency? If yes- Please state name.*

Yes

No

Relative's Name(s)*

Employment Information

Position Applied For:*

For a complete listing of all available positions, click here. If you are applying for any position, please say "General"

Salary Desired*

Presently Employeed*

Yes

No

May we contact your present employer?*

Yes

No

Have you ever applied here before?*

Yes

No

If yes, When?*

Do you have a valid Driver's License*

Yes

No

If yes, which state?*

Have you been a licensed driver for three (3) consecutive years or more?*

Yes

No

Do you have an automobile available for your use?*

Yes

No

Employment Availability*

Full-Time

Part-Time

Substitute

Afternoons

Overnights

Weekends

Check all that apply

Educational Information

Do you have a high school diploma or GED*

Yes

No

You will be required to submit the original document if offered employment.

If you attended college, check the number of years completed*

1

2

3

4

Check all years attended

List any degrees and/or certifications here

Special Skills / Interests Information

Subject of Special Study / Research Work / Previous Experience with Disabled Individuals

What computer skills do you have?*

E-Mail

Social Media

Microsoft Word

Other

Check all that apply

If other- please describe

Were you ever convicted of a criminal offense or have you ever forfeited bond or collateral in connection with a criminal charge?

(The term offense is defined as any felony or misdemeanor, including any summary offense. Omit only (1) minor traffic violations (2) any offense committed before your 18th birthday, which was finally adjudicated in juvenile court or under a youth offender law). Conviction of a criminal offense is not a bar to employment in all cases. Each case is considered on its merit. IF "YES," GIVE DETAILS BELOW. ATTENTION: If you have a criminal conviction or have plead guitly to an offense and you have been told that your record has been expunged ,you must chec "Yes." If "yes," give details below.*

Yes

No

Please give details*

A. "Were you ever, or are you now, excluded from participating in any State or Federal programs such as Medicaid or Medicare?"*

Yes

No

B. "Were you ever, or are you now, listed on any exclusion list of any Federal or State agencies, including but not limited to: The Health and Human Services Office of Inspector General (OIG) List of Excluded Individuals / Entities (LEIE) or the PA Medicheck List?*

Yes

No

Afidavit

Signature*

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Date

Notice to all applicants regarding clearances.

Signature*

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Date

Driving Record Checks

NOTICE: A requirement of almost every position at Diversified Family Services is the capability to drive agency vehicles. dFs performs a driving record check of all employees, post-job offer. dFs may rescind job offers to individuals who have had: • more than two (2) minor moving violations within the past three (3) consecutive years • one (1) major violation within the past three (3) consecutive years • one (1) major violation within the past five (5) consecutive years with any additional violations within the past three (3) consecutive years. dFs will follow the recommendations of their insurance carrier. It is a condition of our insurance carrier that all agency drivers (those who use personal vehicles as part of their job duties,) maintain a minimum of $100,000 aggregate liability coverage. Annually dFs will request certificates of insurance of personal automobile policies.

Has your driver's license been suspended for any reason within the past five (5) consecutive years?*

Yes

No

Signature*

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Date

Employment Application

Personal Information

Employment Information

Educational Information

Special Skills / Interests Information

Employment History

Employer 2

Employer 3

How did you hear about this vacancy?

Authorization

Were you ever convicted of a criminal offense or have you ever forfeited bond or collateral in connection with a criminal charge?

Afidavit

Notice to all applicants regarding clearances.

Driving Record Checks

Invitation to Identify Affirmative Action Survey

Special Employment Notice to Disabled Veterans, Veterans, and Individuals with Physical or Mental Disabilities

We'd Love To Hear From You!

Family, and community is why dFs was formed, and our community is why we are able to grow. Diversified Family Services is here for our friends, families, and our community.
dFs is dedicated to building strong families and a much stronger community.

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Contact Details

Employment Application

Personal Information

Employment Information

Educational Information

Special Skills / Interests Information

Employment History

Employer 2

Employer 3

How did you hear about this vacancy?

Authorization

Were you ever convicted of a criminal offense or have you ever forfeited bond or collateral in connection with a criminal charge?

Afidavit

Notice to all applicants regarding clearances.

Driving Record Checks

Invitation to Identify Affirmative Action Survey

Special Employment Notice to Disabled Veterans, Veterans, and Individuals with Physical or Mental Disabilities

We'd Love To Hear From You!

Family, and community is why dFs was formed, and our community is why we are able to grow. Diversified Family Services is here for our friends, families, and our community. dFs is dedicated to building strong families and a much stronger community.

Employee Login

Latest News

Trainings, Events, Classes and Webinars | April 2024

Transparency In Coverage | 2024

Community Events | 2024

Top 8 Frequently Asked Questions

Contact Details

Family, and community is why dFs was formed, and our community is why we are able to grow. Diversified Family Services is here for our friends, families, and our community.
dFs is dedicated to building strong families and a much stronger community.