Employment Application

Name

Street

City

State

Zip

Phone

Phone (mobile)

E-Mail

Other Name(s)

If hired, can you provide written evidence that you are authorized to work in the United States?

Yes

Are you 18 years of age or older?

Yes

Have you worked for this Agency before?

Yes

If Yes, when?

Have you applied to this Agency before?

Yes

If Yes, when?

Other Referral

Position(s) Applying for:

Do you have any relatives who are a Board or Committee member?

Yes

If so, who?

Do you have any relatives who work for this Agency?

Yes

If so, who?

Hours available to work:

Monday from

Tuesday from

Wednesday from

Do you have a valid driver's license?

Yes

What State?

Have you received a ticket and/or any points on your driving record?

Yes

If yes, describe in detail below. Include dates, if known.

Has your license ever been revoked or suspended?

Yes

If yes, please describe in detail below, including the date of revocation and/or suspension.

Have you ever been convicted of a DWAI, DWI, or DUI?

Yes

If yes, please describe in detail below.

Have you ever been involved in any motor vehicle accident involving harm to anyone or property while driving?

Yes

If yes, please describe in detail below.

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).

Employer Name (1)

Address

Phone

Supervisor

Date from

Position Title

Duties

Reason for Leaving

Employer Name (2)

Address

Phone

Supervisor

Date from

Position Title

Duties

Reason for Leaving

Employer Name (3)

Address

Phone

Supervisor

Date from

Position Title

Duties

Reason for Leaving

Employer Name (4)

Address

Phone

Supervisor

Date from

Position Title

Duties

Reason for Leaving

References

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

Name

Occupation

Phone Number

Name

Occupation

Phone Number

Name

Occupation

Phone Number

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.

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.

Training and Skills

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

Yes

If yes, please describe conviction in detail below.

Are there any pending criminal charges, arrests or criminal accusations against you?

Yes

If yes, please describe in detail below.

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.

Initials

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.

Signature

Date

By checking this box, I am affirming and accepting that all information given within this application is true and accurate.

Advocacy and Resource Center
231 New York Road
Plattsburgh, NY 12903
(518) 563-0930

Equal Opportunity / Affirmative Action Employer
females / minorities / disabled / veterans

Get in touch with us

Advocacy and Resource Center
231 New York Road
Plattsburgh, New York

We value the dreams, aspirations and goals of persons with intellectual and other developmental disabilities and their right to a full, productive and responsible role in society.

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