APPLICATION FOR EMPLOYMENT Unity House of Troy, Inc th Avenue Troy, New York PERSONAL INFORMATION

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1 APPLICATION FOR EMPLOYMENT Unity House of Troy, Inc th Avenue Troy, New York Unity House of Troy, Inc. maintains a commitment to conducting its activities in accordance with applicable laws governing Equal Employment Opportunity. We offer equal opportunity to all qualified employees and applicants for employment without regard to race, creed, color, sex, religion, national origin, age, disability, veteran status, familial status or sexual orientation. PERSONAL INFORMATION Position(s) applied for: Salary Desired $ Name: (Last, First, Middle Initial) : (Street, City, State, Zip Code) Telephone Number: If you are under 18 years of age, please check Employment is subject to verification that you are a minimum legal age. Can you show proof of your eligibility to work in the United States? Yes No Type of employment desired Full time Part time Respite/Substitute (on-call) Referral Source: Unity House employee Name of Employee who referred you: Advertisement Walk-in Employment Agency Please specify which ad: Have you ever worked for Unity House before? Yes No If so, when? Which Program? Have you ever been convicted of a crime, including sex crimes or motor vehicle crimes, in this state or any other jurisdiction? No Yes If yes, please explain: Conviction will not necessarily be a bar to employment. Each instance and explanation will be considered in relation to the position for which you are applying. Hours available to work: Days Evenings Nights Weekends Holidays EDUCATION BACKGROUND *Please list High School; Business, Secretarial or Trade Schools and Colleges Name of School & City, State # Years Attended Major Degree or Diploma Rev. 5/2017 1

2 EMPLOYMENT HISTORY Please give accurate, complete full-time and part-time employment record. Start with your present or most recent employer. If you need additional space, continue on a separate sheet of paper. Employed (Indicate month and year) Pay Start Last Employed (Indicate month and year) Pay Start Last Employed (Indicate month and year) Pay Start Last Employed (Indicate month and year) Pay Start Last Rev. 5/2017 2

3 VOLUNTEER/INTERNSHIP HISTORY Please give accurate, complete volunteer/internship record. Start with your present or most recent volunteer/internship. If you need additional space, continue on a separate sheet of paper. Volunteer Service (Indicate month and year) Volunteer Service (Indicate month and year) Volunteer Service (Indicate month and year) OTHER RELEVANT EXPERIENCE Please indicate any other training, experience (certifications, military, etc.), knowledge, and/or skills you have which are relevant to the position for which you are applying. Rev. 5/2017 3

4 REFERENCES Supervisor References: 1. Name Telephone Number Title and Organization 2. Name Telephone Number Title and Organization 3. Name Telephone Number Title and Organization Personal References: 1. Name Relationship Telephone Number 2. Name Relationship Telephone Number 3. Name Relationship Telephone Number We may contact your previous employers listed in this application unless you indicate otherwise. Please do not contact: Reason: Rev. 5/2017 4

5 DRIVER'S LICENSE CHECK Staff may be required on occasion to drive for Unity House due to the nature of their job. Unity House s insurance requires that the driving records of all employees be checked through the New York State Department of Motor Vehicles. Employees who drive during the workday must have good driving records, if you have more than 6 active points or are excluded by our insurance carrier you will not be able to hold a position that requires driving during the work day. ID #: Issuing State: CERTIFICATION AND AGREEMENT I certify that the information provided on this employment application, my resume and by me verbally at the time of interview is true, complete and correct to the best of my knowledge. I understand that if employed by Unity House, providing inaccurate or misleading information or falsified statements on this application, resume or during interviewing is grounds for disqualification from further consideration or shall be considered sufficient cause for termination from employment. I also certify that I am able to perform the essential functions of the position for which I am applying with or without reasonable accommodation. I expressly authorize, without reservation, the Employer, its representatives, employees or agents to contact and obtain information from all references (personal & professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives, for seeking, gathering and using such information in the employment process and all persons, corporation or organizations for furnishing such information about me. I further understand that the agency, in obligation to complete Exclusion Checks to comply with federal mandates, will be checking my name and personal information (i.e. date of birth and/or social security number) initially, and if hired on a routine basis, against federal and state databases which contain names of individuals/entities who are excluded from any health care program as a result of engaging in fraud or abuse, or for certain other misconduct related to the Federal Health care programs. I understand that an offer of employment is conditional pending these checks by the agency. I understand that the Employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant from consideration for employment on a basis prohibited by applicable local, state or federal law. I understand that this application remains current for only 30 days. At the conclusion of that time, if I have not heard from the Employer and still wish to be considered for employment, it will be necessary to reapply and fill out a new application. If I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice, and the Employer reserves the same right to terminate my employment at any time, with or without cause and without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the Employer is authorized to make any assurances of the contrary and that no implied oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the Employer s president. TO APPLICANTS FOR UNITY SUNSHINE AND TRANSPORTATION PROGRAMS ONLY: I understand that any offer of employment with Unity House is contingent upon my passing any required physical examinations. TO APPLICANTS FOR TRANSPORTATION PROGRAM ONLY: I hereby acknowledge that I may be required to submit a sample of urine for chemical or other analysis as required by law to rule out the presence of prohibited substances in my urine. I voluntarily consent to the request for a urine specimen and agree to participate in the testing program as required. Signature of Applicant Date Rev. 5/2017 5

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