Employment Application

Transcription

1 Employment Application Berkshire Farm Center & Services for Youth (BFCSY) is an Equal Employment Opportunity/Affirmative Action Employer committed to excellence through diversity. We consider all applicants for employment without regard to race, color, religion, sex, national origin, age, marital status, disability, creed, sexual orientation, predisposing genetic characteristics, special disabled veterans, veterans of the Vietnam era, recently separated veterans, armed forces service medal veterans or other protected veterans; or any other legally protected status. APPLICANT INFORMATION Last Name First M.I. Date Street Apartment/Unit # City State Zip Phone Mailing (Only Required if Different from Physical ) Street Apartment/Unit # City State Zip Human Resource Office Route 22, Canaan, NY Phone: Fax: Location(s) & Position(s) applied for: Full-time Part-time Per Diem (Less than 19 hours per week) Desired : Willing to relocate to another BFCSY location : YES UNKWN AT THIS TIME Are you currently employed? YES On what date are you available to work? If Yes, may we contact your current employer? YES Are you on a layoff or subject to recall? YES Are you legally eligible to work in the United States? YES (If hired you will be required to show proof of eligibility to work in the United States in accordance with the Immigration Reform and Control Act of 1986.) Are you above the legal minimum employment age? YES (If a job has a minimum age requirement, you may be required to submit proof of age.) Have you ever worked for BFCSY? YES If so, when? Have you ever applied to BFCSY before? YES If so, when? Position(s) applied for: Can you travel if the position you are applying for requires it? YES Do you have a valid driver s license to operate a motor vehicle? YES If the position you are applying for requires an automobile, do you have one? YES Have you ever been excluded from participation in a Medicare or Medicaid program? YES UNKWN Does your name appear on the NYS Office of Medicaid Inspector General List of Excluded Individuals/Entities (LEIE)? YES UNKWN

2 Have you ever been convicted of a crime? YES If Yes, list all misdemeanors and felonies, including date(s), offense(s) and disposition(s). Attach an additional sheet, if necessary. Do not list criminal convictions under a youth offender status, convictions that have been sealed under New York s Criminal Procedure Law, or adjournments in contemplation of dismissal. A conviction(s) will not automatically disqualify an applicant from employment. Do you have any pending criminal charges against you at this time? YES How did you learn about BFCSY employment opportunities? Check all that apply: Newspaper Job Bulletin /Walk-in Website Dept. of Labor On-line Job Fair Other: Referral by employee If referred by employee, give employee name: EDUCATION NAME OF SCHOOL CITY/ STATE DID YOU GRADUATE? High School: Yes No IF, # OF YEARS LEFT TO GRADUATE IF YES, DATE OF GRADUATION DEGREE RECEIVED MAJOR GED: Yes No Other School: Yes No LICENSE(S)/CREDENTIAL(S) LCSW, RN, LPN, LMSW, MD, NP, PA, CASAC, TEACHER, PSYCHOLOGIST, ETC. STATE TYPE SUBJECT/FIELD/AREA/CERT. EFFECTIVE DATE EXPIRATION DATE CERTIFICATION(S) TYPE SUBJECT/FIELD/AREA/CERT. EFFECTIVE DATE EXPIRATION DATE Have any of your licenses, credentials or certifications ever been revoked, suspended or subject to disciplinary action? YES If Yes, include which license(s)/credential(s) or certification(s), date(s), reason(s) and outcome(s). additional sheet, if necessary. Attach an

3 PERSONAL/PROFESSIONAL REFERENCES: Please provide the name, addresses and telephone numbers of at least three references, other than relatives, who can attest to your character, habits, reputation and personal qualifications. PREVIOUS EMPLOYMENT: Please detail the prior ten years of work history, if. Begin with your most recent employer. If you held multiple positions with the same organization, detail each position separately and attach additional sheets, if necessary. Please explain any gaps in employment. Do not complete this information with the notation See Resume. Company $ Ending $ May we contact your supervisor for a reference? YES Company $ May we contact your previous supervisor for a reference? YES Company $

4 May we contact your previous supervisor for a reference? YES APPLICANT STATEMENT, RELEASE, SIGNATURE AND DATE In making this application for employment I certify, authorize and agree to the following: I certify the information on this application and any supporting documents is/are accurate and complete. I understand and agree that failure to fully complete the form, or misrepresentation or omission of facts on the form, supporting documents or during the interview(s), represents grounds for elimination from consideration for employment, or termination after employment, if discovered at a later date. Any offer of employment I may receive from Berkshire Farm Center & Services for Youth (BFCSY) is contingent upon successful completion of BFCSY's pre-employment screening process, including a background check, fingerprinting, BFCSY receiving references which it considers satisfactory, the provision of appropriate documentation evidencing my legal eligibility for employment in the United States, as required by law, and my satisfactory completion of any post job offer pre-employment physical examination BFCSY may require. In processing my application for employment, BFCSY may verify all the information provided by me, or may secure or have prepared an investigative consumer report for this purpose concerning my prior employment, education, general reputation and personal characteristics. The consumer report or other reports may include, but not be limited to, any of the following: Department of Motor Vehicle records, credit reports, criminal convictions, pending cases, civil cases, current and prior employment verification, education verification, credentials/licensure verification, personal identity verification, sex offender registry and child abuse registry. In addition, I understand I will be required to complete the appropriate forms for BFCSY to be able to conduct the various and required preemployment background checks. I also understand upon written request to BFCSY, I will be informed whether a background consumer report was requested and given full information as to the nature and scope. I further understand that if I am hired by BFCSY, it reserves the right to conduct additional investigative reports as a requirement of maintaining my employment. TE: Applicants in New York State, upon written request, will also be provided with the name and address of the consumer-reporting agency from which BFCSY requested a report, and may also inspect and receive a copy of this report by contacting the consumer-reporting agency directly. If I am offered employment, in consideration of that employment, I agree to comply with the policies, rules, regulations, and procedures of BFCSY. I also understand my employment is at will and it can be my option or BFCSY s option to terminate my employment with or without cause, notice or reason, at any time. It is further understood this "at will" employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of BFCSY. If at any point I am given an employee handbook, I understand it does not constitute an employment contract and represents only guidelines to be applied at the discretion of BFCSY. In addition, BFCSY reserves the right to terminate my employment or modify, amend, suspend or terminate any polices, practices or benefit programs in such handbook at any time. Release: I hereby authorize and request all of my present and former employers and those individuals I have listed as references to furnish information about my employment record, including a statement of the reason for termination of my employment, work performance, abilities, and other qualities pertinent to my qualifications for employment, hereby releasing them and their authorized agents, and all persons and organizations from any and all liability for damages arising from furnishing the requested information. I also authorize and request (1.) the Registrar/Placement Office of all educational institutions attended to release an official copy of my transcript and, if available, faculty appraisals; and (2) any appropriate licensing/credentialing board to release full information concerning my licensure status and my licensure history. Signature Date Optional Attach a Resume and Cover Letter

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