All applications will be kept on file for a period of six months from the date of original submission.
* Required
* Enter this code here: (Note: If you cannot read the code in the image, Click the button.)
Employee No.
(If previous commonwealth employee)
Work County Preference
* 1st Preference 2nd Preference 3rd Preference
 
Personal Data
* Last Name  
* First Name  
Middle Initial
* Address  
* City/Boro/Township  
State Pennsylvania
* Zip Code  
* County  
*
Home Phone No. or
Cell Phone No.
 
* Email Address  
General Information
1. Do you have a relative currently employed with the Pennsylvania Liquor Control Board (PLCB)? If yes, please state below the name and your relationship to the employee.
*  
Name Relationship
2. Have you ever been dismissed from employment for inefficiency, delinquency, or misconduct, or have you ever been permitted to resign to avoid dismissal? Explain below.
*  
Explain
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.
*  
Explain
4. Have you previously worked for the Commonwealth?
*  
If Yes:
Start Date End Date Agency
Start Date End Date Agency
5. If employed by the PLCB, would you continue employment with another company? If yes, you will be required to complete form STD-355, Supplementary Employment Request. You will be notified of the approval/disapproval of your request.
 
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.
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 office 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:  (17 or older)      
(This information is required to conduct a criminal history background check)
PLEASE LIST MAIDEN NAME (OR ANY ALIAS NAMES) WHICH RECORDS MAY BE UNDER
1. Have you been convicted of a felony in the last (10) years? If yes, please give details below.
*  
Date of arrest Crime(s) charged
Place of arrest:
City State County
Comments - use this space to explain ‘yes’ answer.
2. Are there criminal charges of any kind pending against you at this time? If yes, please give details below.
*  
Date of arrest Crime(s)
Place of arrest:
City State County
Comments - use this space to explain ‘yes’ answer.
3. Have you ever been convicted, fined, 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.
*  
Date of arrest Crime(s)
Place of arrest:
City State County
Comments - use this space to explain ‘yes’ answer.
4. Are you currently participating in an Accelerated Rehabilitative Disposition (ARD) Program or other court-ordered program to avoid conviction?
*  
Date of granting ARD Date of completion Crime(s)
Location of supervising court:
City State County
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 education and conviction records. Therefore, by clicking "Submit 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 sufficient 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 verified.
The PA Liquor Control Board is proud to be an equal opportunity employer supporting workforce diversity.