Job Application

Federal and state laws prohibit discrimination in employment because of sex, age, race, color, religious creed, marital status, national origin, ancestry, disability or handicap.

Instructions to Applicant: Please read carefully. Every item on this form must be answered to the best of your ability. Your qualifications will be reviewed and you will be given thorough consideration for any applicable vacancies. If you are employed by this agency, this form will become a part of your personnel file.

Applicants are not required to give any information on this form that is prohibited by Federal, State or Local Law.

Personal Information
What position are you applying for?
Full Name:
Address:
City:
State:
Zip:
E-mail:
Phone Number:
Mobile/Other:
Social Security Number:
If under 18 years of age, do you have a work permit?
Are you a citizen of the United States?
If NOT, do you have the legal right to remain permanently and work in the United States? (Proof of citizenship or immigration status will be required upon employment)
Provide Alien Registration Number if not a citizen of the United States:
Your Rate of Pay Expected:
Date you can start:
Have you ever applied to this company before?
If YES, when:
Have you ever worked for this company before?
If YES, when - please give Supervisor Name, Facility Name, Location of Facility & Reason for leaving:
Do you have any friends or relatives employed by this company?
If YES, Name, Relationship to you Facility Name, Location of Facility & Position:
Have you ever worked for this company under a different name?
If YES, what name?
Is any additional information related to a change of name, use of an assumed name, or nickname necessary to enable verification of your work record?
If YES, please explain:
Can you perform the essential functions of the job with or without a reasonable accommodation?
If YES, please describe:
Do you have a valid NY state driver's license?
If NO, please explain:
Do you have an out of state license?
Have you received any moving violations in the past 8 years?
If YES, give dates/details:
Have you had any suspension, revocation, DWI, DWUI, or any occurrence involving harm to anyone or property while driving?
If YES, give dates/details:
Method of transportation to work:
What foreign languages do you speak, read and/or write fluently?
Indicate your availability:


Type of employment desired:


Are you on a layoff and subject to recall?
Can you travel if the job requires?
Are you involved in any activity which would interfere with regular work scheduling?
If YES, please explain:
Referral source:
Summarize Your Special Skills or Qualifications:
Are you currently employed?
If yes, may we contact your present employer?
Have you ever been discharged or asked to resign by any former employer?
If YES, please explain:
Military Record
Were you in the US Armed Forces?
Rank at discharge:
Type of discharge:
List duties in the service including special training:
 
Record of Employment 1 (begin with your present or last job)
Dates of Employment: From:   To:   
Positions(s) Held:
Employer Name:
Address of Employer:
Employer Phone Number:
Supervisor:
Title of Supervisor:
Your Responsibilities:
Start Rate of Pay & Title:
End Rate of Pay & Title:
Reason for Leaving:
May we contact this employer for reference ? Yes     No
 
Previous Employment 2
Dates of Employment: From:   To:   
Positions(s) Held:
Employer Name:
Address of Employer:
Employer Phone Number:
Supervisor:
Title of Supervisor:
Your Responsibilities:
Start Rate of Pay & Title
End Rate of Pay & Title
Reason for Leaving:
May we contact this employer for reference ? Yes     No
 
Previous Employment 3
Dates of Employment: From:   To:   
Positions(s) Held:
Employer Name:
Address of Employer:
Employer Phone Number:
Supervisor:
Title of Supervisor:
Your Responsibilities:
Start Rate of Pay & Title
End Rate of Pay & Title
Reason for Leaving:
May we contact this employer for reference? Yes     No
 
References
Full Name:
Company: 
Address:
Relationship:
Phone Number:
 
Full Name:
Company:
Address:
Relationship:
Phone Number:
 
Full Name:
Company:
Address:
Relationship:
Phone Number:
 
Record of Education
Elementary School:  (Name and Address)
Course of Study
Last Year Completed:
Did you graduate:
Diploma or Degree:
 
High School: (Name and Address)
Course of Study:
Last Year Completed:
Did you Graduate:
Diploma or Degree:
 
College:  (Name and Address)
Course of Study
Last Year Completed:
Did you graduate:
Diploma or Degree:
 
Other: (Name and Address of School)
Course of Study:
Last Year Completed:
Did you Graduate:
Diploma or Degree:
 
Professional Licenses / Certifications (if any)
Type:
State(s) Valid:
Number:
Valid Since:
List Professional, Trade or Business Organizations to which you belong:
 
Emergency Contact
In case of emergency, please notify:
Relationship:
Address:
Phone:
Applicant's Statement

I understand that any employment by this property/facility will be on a probationary basis. If employed by the facility I agree to abide by all rules indicated in the company handbook, facility/property policies and procedures as well as applicable state regulations governing this facility/property. I further understand that this employment application is not and is not intended to be an employment contract. I certify that the above information is complete and true to the best of my knowledge. I understand that discovery of misrepresentation or omission of facts herein will be cause for immediate dismissal regardless of when this is discovered. I hereby authorize this facility to contact any and/or all of the references and former employers listed in this application to obtain any information, which in employers discretion, it deems necessary to make an employment decision. I agree to take an occupational physical to be conducted by a physician selected by the employer at any time if I am offered employment and agree that the examining physician may disclose the results to my employer or an authorized agent of the employer.

Name:     Date: 
 I agree to the above Applicant's Statement
 
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