Employment Application - Pathway Services Unlimited Inc.

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Applicant Information

First Name *

Middle Initial

Last Name *

Phone Number *

Email Address *

Cell Phone Number

Social Security Number *

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Are you a citizen of the United States or a lawfully immigrated alien, legally eligible to work? *YesNo

Do you have a drivers license? *YesNo

In no, please list your state ID information below.

Issuing State *

Drivers License/State ID # *

Expiration Date *

Date of Birth *

Background Check

Background Check Information

We are required to complete background checks on all employees. Please complete the following information.

A Health Care Worker registry check is required by Illinois law and/or the Agency. An applicant / employee for any position in our Agency shall not be hired and may be terminated if the Health Care Worker registry report indicates such person is identified as having substantiated findings of abuse, neglect, egregious neglect or financial exploitation. There is no charge for this registry check. Please complete the following information:

Have you ever been convicted of a crime other than a minor traffic violation? A “yes” answer will not automatically eliminate your application from consideration. You are not obligated to disclose sealed or expunged records of conviction or arrest. *YesNo

If yes, list all pertinent details; including date and offense for which you were convicted: *

I certify that the answers given herein are true and complete to the best of my knowledge.

I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. I understand that this application is not intended to be a contract of employment, and further, that if employed, my employment is on an at will basis and may be terminated at my discretion or at the discretion of Pathway Services Unlimited.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in dismissal from employment.

I hereby give permission to check on the information provided in this form.

Name *

Date *

Pathway Services Unlimited, Inc. is an equal opportunity employer and does not discriminate based on actual or perceived race, gender, ancestry, order of protection status, sex, creed, religion, color, marital status, parental status, age, military status, pregnancy or maternity, national origin, political affiliation and/or beliefs, veteran status, mental or physical disability, citizenship status, unfavorable discharge from the military, disability, genetic information, sexual orientation or any other individual characteristic protected by applicable law.