PlCB-1817 9/08 |
SEASONAL LiquOR STORE cLERk |
Bureau Of |
Pennsylvania |
liquOr COntrOl BOarD |
EmPLOymENT APPLicATiON |
Human resOurCe management |
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sOCial seCurity nO. |
emPlOyee nO. (if previous Commonwealth employee) |
WOrk COunty PreferenCe |
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PERSONAL DATA
mailing aDDress (street, P.O. BOX)
vOting aDDress (if Different frOm mailing aDDress) (street, P.O. BOX)
COunty
yes nO |
GENERAL iNFORmATiON |
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1.Do you have a relative currently employed with the liquor Control Board? if yes, please state below the name and your relationship to the employee.
2.Have you ever been dismissed from employment for ineficiency, delinquency, or misconduct, or have you ever been permitted to resign to avoid dismissal? explain below.
3.If you resigned from a position, did the resignation occur after receiving information from your employer indicating you may be disciplined? If so, please explain below.
4.Have you previously worked for the Commonwealth?
If yes: Date:___________________________________ Agency_________________________________________________
Date:___________________________________ Agency_________________________________________________
COmments:
cONFLicT OF iNTEREST
a COnfliCt Of interest PrOHiBits emPlOyment WitH tHe Pennsylvania liquOr COntrOl BOarD in aCCOrDanCe WitH tHe liquOr CODe seCtiOn 210. emPlOyment CannOt Be OffereD until tHe COnfliCt is resOlveD. a “yes” ansWer tO any Of tHe fOllOWing questiOns may inDiCate a COnfliCt Of interest. ATTACH ADDITIONAL SHEETS tO eXPlain “yes” ansWers. inCluDe yOur name anD sOCial seCurity numBer On eaCH attaCHeD sHeet.
yes nO
1.Do you or any member of your immediate family* hold any license issued by the Pennsylvania liquor Control Board? if so, what type of license(s)?
2.Do you or any member of your immediate family* hold ofice in any organization which holds a License issued by the Pennsylvania Liquor Control
Board?
3.Do you or any member of your immediate family* have any direct or indirect interest in any business within the Commonwealth dealing in liquor, or alcohol, or malt or brewed beverages, whether as owner, part-owner, partner, member of syndicate, shareholder, independent contractor, manager or agent?
* mEmBERS OF immEDiATE FAmiLy cONSiSTS OF THE FOLLOWiNG: SPOuSE RESiDiNG iN THE PERSON’S HOuSEHOLD AND miNOR DEPENDENT cHiLD.
ARREST/cONvicTiON/ARD iNFORmATiON
fOr tHese questiOns DisregarD: summary traffiC viOlatiOns (nO POints), Offenses COmmitteD BefOre yOur 18tH BirtHDay WHiCH Were aDjuDiCateD in juvenile COurt unDer a yOutH OffenDer laW, anD any CHarges WHiCH Have Been eXPungeD By a COurt Or fOr WHiCH yOu suCCessfully COmPleteD an aCCelerateD reHaBilitative DisPOsitiOn PrOgram.
cRimiNAL OFFENSE: inCluDes felOnies, misDemeanOrs anD summary Offenses.
cONvicTiON: an aDjuDiCatiOn Of guilt anD inCluDes DeterminatiOns BefOre a COurt, a DistriCt justiCe Or magistrate anD Pleas Of nO COntest tHat result in a fine, sentenCe Or PrOBatiOn.
COnviCtiOns WHiCH OCCur after aCCePtanCe Of emPlOyment WitH tHe PlCB may result in yOur Dismissal.
Date Of BirtH |
mOntH |
Day |
year |
(This information is required to conduct a criminal history background check) |
Please list maiDen name (Or any alias names) WHiCH reCOrDs may Be unDer
yes nO
1. Have you been convicted of a felony in the last (10) years? if yes, please give details below.
COmments - use tHis sPaCe tO eXPlain ‘yes’ ansWer.
yes nO
2. Are there criminal charges of any kind pending against you at this time? if yes, please give details below.
COmments - use tHis sPaCe tO eXPlain ‘yes’ ansWer.
yes nO
3. Have you ever been convicted, ined, sentenced, placed on probation, pled guilty or no contest, or forfeited bond in the uS or any foreign country as a result of being arrested, charged or cited.
COmments - use tHis sPaCe tO eXPlain ‘yes’ ansWer.
yes nO
4. Are you currently participating in an Accelerated Rehabilitative Disposition (ARD) Program or other court-ordered program to avoid conviction?
lOCatiOn Of suPervising COurt
terms Of arD
Please reaD Carefully
As a condition to your continued employment, you may be subjected to searches of your person and your possessions when on and/or leaving Commonwealth premises. In the event any property of the PLCB is found in your possession, you will be subject to immediate discharge and prosecution under the law.
The PLCB may conduct investigations regarding medical history, education and conviction records. Therefore, by signing this application you are authorizing the release of the above information to the PLCB and you indicate your awareness that false statements or failure to disclose information may be suficient to disqualify you for employment
or, if employed, may result in your dismissal.
I further understand that employment is conditional until results of information given by me here have been reviewed, considered, and veriied.
THE PA LiquOR cONTROL BOARD iS PROuD TO BE AN EquAL OPPORTuNiTy EmPLOyER SuPPORTiNG WORkFORcE DivERSiTy