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Personal Information

 

 

 

 

 

 

Educational Background

High School
Undergraduate
Graduate
Associates
GED





Employment History












Hours per week: Full Time
Part Time
Per Diem



Were you asked to leave?: Yes
No

Availability
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Biographical Data

Where you referred by a current employee?

Have you submitted an application for employment with our agency before?

Have you thoroughly read the job description?

Are you able to complete all of the essential functions and duties of the job with or without accomodations?

Are you legally eligable to work in the US?

Conviction Record Status

Have you ever been convicted of a felony or misdemeanor in this state or any other jurisdiction?

If you answered 'yes' and have been convicted of a felony or misdemeanor, please provide additional information such as the crime(s), date(s), court location, sentencing information, disposition of sentance, and rehabilitation completed. Please note that a 'yes' answer to this question does not necessarily disqualify an applicant from employment. Misrepresentation or omission of facts will disqualify an applicant or be cause for dismissal of employment.


State Central Registry

Have you ever been the subject of an indicated report of child abuse or maltreatment?

An indicated report of child abuse or maltreatment is a report on file with the Statewide Central Register of Child Abuse and Maltreatment of the New York State Office of Children and Family Services because some credible evidence exists to support that you have been involved in a case of child abuse and/or mistreatment.

I have recieved notice of the requirements of social services Law 424-a, and I understand that if information regarding my past history with the Statewide Central Register of Child Abuse and Maltreatment is contained in a report from the Register, it will be used to determine my sustainability to take a position that involves regular and substantial contact with individuals recieving services. I further understand that any misrepresentation of my status or of the information given will result in administrative action which may include dismissal or discipline.



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