Employment Application

Education History

Please include names and addresses of the schools and/or programs you have attended.

High School

College

Additional College

Technical Training

Driving Record

Employment History

Please include the names, addresses and phone numbers of your previous employers where applicable. List most recent first and provide all information requested (no blanks).

References

Please list 3 personal references. They cannot be relatives or anyone listed above.

Other Related History

Please list below any prior or current experience as an employee, volunteer or provider with the New York State Office for People with Developmental Disabilities (OPWDD), any other state agency or any other human services provider.

Also list any other experience you have in direct care work relevant to the position for which you are applying. Employment listed on the preceding page under Employment History need not be repeated here. Please provide the names, addresses and telephone numbers for references who can verify each experience.

Please list any other special training or skills you have or any courses you have taken that relate to the type of services our Agency provides.

Please be advised that you will need to provide information, statements and fingerprints according to the requirements of the Agency, the NYS Justice Center and OPWDD, in order for a background check to be conducted through DCJS. Also you will have the right to obtain, review and seek correction of any information received in response to the criminal background check conducted by DCJS.

My signature below authorizes you to contact all my previous and current employer(s) and references.

This application is not intended as a contract of employment nor does this application obligate the employer in any way if the employer decides to hire me.

By signing below, I certify that the information I have provided in this application is true and complete. I understand that if employed, any false statement or information that I have provided on this application may result in termination of my employment.