The Handicapped Children's Association of Southern NY,
Inc.
18 Broad Street
Johnson City, NY 13790
(607) 798-7117
APPLICATION FOR EMPLOYMENT
We are an equal opportunity employer and do not unlawfully discriminate
in employment. No question on this application is used for the purpose of
limiting or excluding any applicant from consideration for employment on a basis
prohibited by local, state, or federal law. Equal access to employment,
services, and programs is available to all persons. Those applicants requiring
reasonable accommodation to the application and/or interview process should
notify a representative of the organization.
Date:__________________
Position(s) applied for or type of work desired: (please circle)
Residential/respite/reshab clinical preschool volunteer any
Applicant name:__________________________________
Address:_________________________________ Telephone #:_____________
Social Security #:_______________________
Type of Employment desired: ___ fulltime ___ part time ___ substitute
Date you will be available to start work: _________________________________
Do you have my objection to working overtime if necessary? __ yes __ no
Can you travel if required by this position? __ yes __ no
Have you ever been previously employed by our organizations? __ yes __ no
Can you submit proof of legal employment authorization and identify? __ yes __
no
Do you currently have any criminal charges pending against you? __ yes __ no
If yes, please explain: ____________________________________
_____________________________________________________________
Have you ever been convicted of a crime? __ yes __ no
If yes, please explain (a conviction will not automatically bar employment):
___________________________________________________________________________________________________
Do you have a valid driver's license? __ yes __ no Driver's License #:________
Have you been convicted of moving violation(s), any license suspensions or
revocations, DWI conviction(s), or any occurrence involving harm to personal
property while driving? __ yes __no
If yes, please explain (a conviction will not automatically bar employment):
______________________________________________________________________________
______________________________________________________________________________
How were you referred to us?
___________________________________________________________________
Employment History
Please provide all employment information for your past four employers starting
with the most recent.
Employer:______________________________ Position held:________________
Address: ____________________________________ Telephone #:___________
Immediate supervisor and title: _________________________________________
Dates employed: from__________ to___________ Salary: ___________________
Job summary: _______________________________________________________
Reason for leaving: __________________________________________________
Employer:______________________________ Position held:________________
Address: ____________________________________ Telephone #:___________
Immediate supervisor and title: _________________________________________
Dates employed: from__________ to___________ Salary: ___________________
Job summary: _______________________________________________________
Reason for leaving: __________________________________________________
Employer:______________________________ Position held:________________
Address: ____________________________________ Telephone #:___________
Immediate supervisor and title: _________________________________________
Dates employed: from__________ to___________ Salary: ___________________
Job summary: _______________________________________________________
Reason for leaving: __________________________________________________
Employer:______________________________ Position held:________________
Address: ____________________________________ Telephone #:___________
Immediate supervisor and title: _________________________________________
Dates employed: from__________ to___________ Salary: ___________________
Job summary: _______________________________________________________
Reason for leaving: __________________________________________________
Other Skills and Qualifications
Summarize any job-related training, skills, licenses, certificates, and/or other
qualifications:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Prior or current experience as an employee, volunteer or
certified provider with OMRDD or any other State Agency or other provider of
human services:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Educational History
List school name and location, years completed, course of study, and any degrees
earned:
High School:_______________________________________________________
College:________________________________________________________________
Technical Training:___________________________________________________
Other:__________________________________________________________________
References
List 4 references, (at least 2 personal). Provide names, telephone numbers, and
years known. (Do not include relatives):
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
I hereby authorize the potential employer to conduct, obtain, and
verify the accuracy of information contained in this application from all
previous employers, educational institutions, and references. I also hereby
release from liability the potential employer and its representatives for
seeking, gathering, and using such information to make employment decisions and
all other persons or organizations for providing such information.
I understand that any misrepresentation or material omission made by me on
this application will be sufficient cause for cancellation of this application
or immediate termination of employment if I am employed, whenever it may be
discovered.
If I am employed, I acknowledge that there is no specified length of
employment and that this application does not constitute an agreement or
contract for employment. Accordingly, either the employer or I can terminate the
relationship at will, with or without cause, at any time, so long as there is no
violation of applicable federal or state law.
I understand that it is the policy of this organization not to refuse to hire
or otherwise discriminate against a qualified individual with a disability
because of that person’s need for a reasonable accommodation as required by ADA.
I also understand that if I am employed, I will be required to provide
satisfactory proof of identity and legal work authorization within three days of
being hired. Failure to submit such proof within the required time shall result
in immediate termination of employment.
I represent and warrant that I have read and fully understand the foregoing,
and that I seek employment under these conditions.
Applicant signature: ______________________________ Date:__________