Maiden Name (if applicable):
***Best Contact Number:
Reference 1 Name:
Reference 1 Phone Number:
Relationship to Reference 1:
Reference 2 Name:
Reference 2 Phone Number:
Relationship to Reference 2:
Highest Degree Obtained:
Number of years completed:
Course of study/major:
Diploma or Degree obtained:
Supervisor Name and Title:
Number of Hours:
Reason for Leaving:
Where you referred by a current employee?
If yes, what was the employee's name?:
Additional Positions applying for:
Salary or Wage Desired:
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?
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.
Date of Offense:
County and State in which offense occured:
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.