Application for Employment If you are a human and are seeing this field, please leave it blank. Personal Information Fields marked with an * are required First Name * Middle Name * Last Name * Email * Address 1 * Address 2 City * State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip / Post Code * Phone * Cell Phone If necessary, best time to call you at home is Do you have a valid New York State Driver’s License? * YesNo For those positions involving direct work with children, you may be asked to help control or restrain the aggressive behavior of an emotionally disturbed child. Would you be comfortable in this situation, and physically able to handle this behavior? * YesNo If no, please explain Do you have any outside commitments that would conflict with our work schedule? * YesNo If yes, please explain Have you ever been convicted of a crime? * YesNo If yes, please explain Have you ever been convicted of a criminal offense related to health care? YesNo If yes, please explain Have you ever experienced a debarment, exclusion or ineligibility as a participant in a federal health care program? YesNo If yes, please explain Will you work overtime if required? * YesNo Type of employment desired Full-Time Part-Time Intern Choose One Date available to start * Are you legally eligible for employment in this country? * YesNo Have you ever been employed here before? * Have you submitted an application here before? * May we contact you at work? YesNo If yes, work number and best time to call General Information Equal access in programs, services and employment is available to all persons. Those applicants requiring reasonable accommodation to the application and/or interview process should notify a representative of the Human Resources Department. Position(s) Applied for Salary Desired Referral Source Walk In Employee Relative TV Advertisement Social Media Newspaper Advertisement Government Employed Agency College/University Placement Office Private Employment Agency Job Fair Choose One Name Source (if applicable) Employment History Provide the following information for your past and current employers, assignments or volunteer activities, starting with the most recent. Explain any gaps in employment in the comment section below. Employer (Most Recent) Job Title Summarize the type of work performed and job responsibilities Dates employed Address 1 Address 2 Supervisor Name and Title Phone Hourly Rate/Salary (Starting) Hourly Rate/Salary (Final) Reason for leaving May we contact for reference? Yes No Later Employer 2 Job Title Summarize the type of work performed and job responsibilities Dates employed Address 1 Address 2 Supervisor Name and Title Phone Hourly Rate/Salary (Starting) Hourly Rate/Salary (Final) Reason for leaving May we contact for reference? Yes No Later Employer 3 Job Title Summarize the type of work performed and job responsibilities Dates employed Address 1 Address 2 Supervisor Name and Title Phone Hourly Rate/Salary (Starting) Hourly Rate/Salary (Final) Reason for leaving May we contact for reference? Yes No Later Comments (Including any explanation of gaps in employment) Skills and Qualifications – Summarize any special training, skills, licenses and/or certifications that may qualify you as being able to perform job-related functions in the position for which you are applying. Educational Background Fields marked with an * are required List last (3) schools attended, starting with most recent. List number of years completed. Indicate whether or not you graduated. Indicate degree or diploma earned Major field of study. Minor field of study (If applicable) School * Years * Graduated * Degree/Diploma * Major Minor School Years Graduated Degree/Diploma Major Minor School Years Graduated Degree/Diploma Major Minor References Fields marked with an * are required List name and telephone number of three business/work references who are NOT related to you. If not applicable, list three school/personal references who are NOT related to you. First and Last Name * Reference's Phone Number * Years Known * First and Last Name * Reference's Phone Number * Years Known * First and Last Name * Reference's Phone Number * Years Known * Additional Information Additional Information: List professional, trade, business or civic associations and offices held. (Exclude memberships which would reveal race, creed, national origin, religion, age, disability, marital status, orientation or citizenship status) Organization Offices Held Organization Offices Held Organization Offices Held List special accomplishments, publications, awards, etc. (Exclude memberships which would reveal race, creed, national origin, religion, age, disability, marital status, orientation or citizenship status) List any additional information you would like us to consider. Submission Page Fields marked with an * are required I understand that if I am employed, any misrepresentation or material omission made by me on this application will be sufficient cause for cancellation of this application or immediate discharge from the employer’s service, whenever it is discovered. I give the employer the right to contact and obtain information from all references, employers, educational institutions and otherwise verify the accuracy of the information obtained in the application. I hereby release from liability the employer and its representatives for seeking, gathering, and using such information and all other persons corporations or organization for furnishing such information. The employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant from consideration for employment on a basis prohibited by local, state or federal law. If I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and without prior notice, except as required by law. This application does not constitute an agreement or contract for employment for any specific period or definite duration. I understand that no representative of the employer, other than an authorized officer, has the authority to make any assurances to the contrary. I further understand that any such assurances must be in writing and signed by an authorized officer. I understand that if I am employed, a criminal conviction clearance may be done as required by Social Services Law. I understand that although this Agency makes every effort to accommodate individual preferences, the nature of our program may involve a work schedule other than Monday-Friday. I understand that a medical examination is required by Social Services Law for all employees. I understand that it is this Agency’s policy not to refuse to hire a qualified individual with a disability because of that person’s need for reasonable accommodation as required by the ADA. I also understand that if I am hired, I will be required to provide proof of identity and legal work authorization. I represent and warrant that I have read and full understand the foregoing and seek employment under these conditions. I agree to the terms above. * Upload Resume 1 + 1 = * It may take a minute to process the form. Please only press the submit button once. A success message will appear and you will also receive a copy of the application. Thank you!