Application for Employment

You are applying for: Director of Finance, Community Services for the Developmentally Disabled

Date of Application Email
First Name Middle Name Last Name Telephone
Current Address City State Zip
Previous Address: City: State: Zip:
Position(s) Applying for (please specify): Rate of pay expected:
Preferred Shift: Weekdays:
DaysEveningsOvernights
Weekends:
DaysEveningsOvernights
Do you have any restrictions, personal or otherwise, which would restrict the hours you can work?
If yes, identify days/hours you are not available:
Referral Source: Employee Name: Newspaper Name:
Internet Site Name: Walk-in Applicant: Other: (please specify):
Have you ever been employed here before? If so, when and what position?
Are you prevented from lawfully becoming employed in this country because of Visa or immigration status?
Are you 18 years of age or older? If not, how old? Do you have working papers?
Are you currently employed? If not, how long since leaving last employment?
Please include your current resume if available 

Education

High School: City: State: Highest Grade Completed:
Did You Graduate? Degree Earned:
College: City: State: Highest Grade Completed:
Did You Graduate? Degree Earned:
College: City: State: Highest Grade Completed:
Did You Graduate? Degree Earned:
Graduate School: City: State: Highest Grade Completed:
Did You Graduate? Degree Earned:
Technical, Business, or Other: City: State: Highest Grade Completed:
Did You Graduate?: Degree Earned:
Please indicate if you hold any of the following up to date certifications:
First AidCPRMedicationSCIP/R

Employment History

(Start with your present or most recent position. Include experience in the armed forces of the U.S. Account for all periods of time. Please fill out all information, even if attaching resume.)

Please list all human services agencies or OPWDD providers that you have worked for in the employment history - attach additional pages if necessary.

Present /Most Recent Employer Name: Type of Business:
Address: City: State:
Telephone Number: Dates of employment: (month/year) To:
Position: Pay Rate:
Reason for Termination/Separation:
Last immediate supervisor's name and title:
Employer Name: Type of Business:
Address: City: State:
Telephone Number: Dates of employment: To:
Position: Pay Rate:
Reason for Termination/Separation:
Last immediate supervisor's name and title:
Employer Name: Type of Business:
Address: City: State:
Telephone Number: Dates of employment: To:
Position: Pay Rate:
Reason for Termination/Separation:
Last immediate supervisor's name and title:
Employer Name: Type of Business:
Address: City: State:
Telephone Number: Dates of employment: To:
Position: Pay Rate:
Reason for Termination/Separation:
Last immediate supervisor's name and title:
Describe specialized training, apprenticeships, skills and extra-curricular activities: summarize special skills and qualifications you have acquired from employment or other experience, including seminars or workshops completed. Do not include any organization which may indicate your political affiliation, age, religion, national origin, color, marital status, sexual orientation, disability, veteran status, domestic violence victim status or genetic predisposition or other protected status.

References

Personal: (Please do not include relatives.)

Name: Address: City: State:
Telephone:
Name: Address: City: State:
Telephone:
Name: Address: City: State:
Telephone:

Professional: (Please provide information for present or former supervisors.)

Name: Company: Job Title: Telephone:
Name: Company: Job Title: Telephone:
Name: Company: Job Title: Telephone:
* Have you been convicted of a felony or misdemeanor in any jurisdiction? If yes, please provide explanation:
Your answer is looked upon as only one of the factors considered in the employment decision and is evaluated in terms of the nature, severity, and date of the offense. No applicant will be excluded from consideration for employment due to prior arrests.
City: State: Date: Charge:
Disposition:
Responses to the questions below are required of all applicants applying for a position that will have direct contact with individuals receiving services.
1) Have you ever had any substantiated allegations of abuse while working at a human services agency/OPWDD provider?
Your answer is looked upon as only one of the factors considered in the employment decision and is evaluated in terms of the nature, severity, and date of the allegation.
If yes, please provide details without breaking any HIPAA or confidentiality rules: Month and Year of allegation(s):
2) Are you listed on a child abuse registry or have you ever been the subject of a finding, indicated case of or determination of child abuse or maltreatment by any agency or organization including government or internal investigation?
If yes, please provide explanation: Date: City: State:
3) Do you have any pending arrests/criminal charges? If yes, please provide explanation:
4) Are you the subject of any pending child abuse or maltreatment cases by any agency or organization? If yes, please provide explanation:
New York State Human Rights Law and Federal Equal Employment Opportunity Law prohibit discrimination because of race, creed, religion, color, national origin, sex, marital status, age, sexual orientation, disability, veteran status, arrest record, domestic violence victim status or genetic predisposition.

Applicant's Agreement:

I hereby represent that each answer to a question herein and on any attachments to the application, and all other information otherwise furnished is true and correct. I further represent that such answers and information constitute a full and complete disclosure of my knowledge with respect to the question or subject to which the answer or information relates. I understand that any incorrect, incomplete or false statements or information furnished by me during the selection process will subject me to disqualification from consideration or discharge at any time. I hereby authorize my former employers to give any information regarding my employment with them; and in addition, to furnish any other information they may have concerning me.

I understand this Application for Employment does not constitute an expressed or implied contract of employment and, if hired, I have the right to terminate my employment for any reason at any time. I also understand Community Services reserves the same rights. I understand I may be subject to and I authorize Child Abuse, Criminal Background and Driving Abstract checks by Community Services. I understand this may include the use of fingerprinting. I understand Community Services reserves the right to unilaterally change or modify "wage" and "conditions of employment" at any time without previous notice.

I further understand that in the event I receive an offer of employment, I will be required to submit to a post-offer drug test. The offer of employment will be revoked, or employment will be terminated, in the event of a positive test result. Any offer of employment will be revoked, or employment will be terminated based on adverse information obtained by Community Services, OPWDD, or OMH during the background investigation process.

   I agree

Note: Employment applications are only considered active for sixty (60) days from receipt. Applications containing stray remarks and/or attachment, and/or information not specifically requested on the application, other than resumes, will be disqualified from further consideration. Incomplete applications may be disqualified from further consideration.

Community Services for the Developmentally Disabled is a drug- free and smoke-free work place.

Consumer Report Disclosure Statement:

In compliance with the Fair Credit Reporting Act (Public Law 91-508), you are notified that in connection with and in order to better evaluate this application for employment, a report may be obtained which will provide applicable information concerning character, general reputation and personal characteristics including, but not limited to, verification of prior employment, verification with the Department of Motor Vehicles, and a character check, including verification and review of any criminal convictions. You have the right to make a written request within a reasonable period of time for a complete and accurate disclosure of the nature and scope of the report requested.

I hereby authorize Community Services for the Developmentally Disabled to procure a consumer report as set forth above.

   I agree

Driver's Supplement

Driver License Information (Must be completed by all applicants for positions that include driving as an essential function of the job. All persons who drive Community Services vehicles must have a valid New York State Driver License. Please see the list provided with this application to see if the position you are applying for requires you to complete this section of the application. If you did not receive a list with this application, please ask our Receptionist for a copy.)

State: Class: Expiration Date:
Driver's License Restrictions:
* A. Have you ever been denied a license, permit or privilege to operate a motor vehicle?
* B. Has any license, permit or privilege ever been revoked by any state?
* C. Is your New York State Driver License currently suspended?
If the answer to A, B, or C is "Yes", please explain:

Traffic Convictions and Forfeitures

List alcohol or drug related offenses during the past 5 years.

List all other traffic convictions (moving and non-moving violations) during the past 2 years. Do not list parking violations.

  
None
Court Location: Date of Conviction: Charge: Penalty: Points:

Accident Record

during the past 3 years involving persons and/or property.

  
None
Date of Accident: City: State: Nature of Accident: Fatal?
Use the area below to explain any of the above information concerning the accidents and traffic convictions listed:

Access to private transportation is an essential function of many Program positions. Please see the list provided with this application to see if the position you are applying for requires you to complete the question below. If you did not receive a list with this application, please ask our Receptionist for a copy. Any individual accepting one of these positions will be required to use their private transportation throughout the day. If you are applying for one of these positions, please answer the question below.

Do you have access to private transportation to use while at work?

I understand that this Driver Supplement is an attachment to the Application for Employment and I hereby represent that each answer is true and correct. The Applicant's Agreement on the Application for Employment also applies to my answers on this supplement.

  I agree

Authorization For Release Of Personal Information

I do hereby authorize a review of and full disclosure of all records concerning myself to Community Services for the Developmentally Disabled, its agents and representatives, whether the said records are of public, private or confidential nature.

The intent of this authorization is to give my consent for full and complete disclosure. I understand that any information obtained by a personal history background investigation, which is developed directly or indirectly, in whole or part, upon this release authorization will be considered in determining my suitability for employment. I also certify that any person(s) who may furnish such information concerning me shall not be held accountable for giving this information, and I do hereby release said person(s) from any and all liability which may be incurred as a result of furnishing such information. I further release Community Services for the Developmentally Disabled, its agents and representatives, from any and all liability, which may be incurred as a result of collecting such information.

Community Services for the Developmentally Disabled is an equal opportunity employer and prohibits discrimination because of race, creed, color, national origin, sex, sexual orientation, age, disability, arrest record, domestic violence victim status or genetic predisposition.

Your criminal background is only one of the factors considered in the employment decision and is evaluated in terms of the nature, severity and date of the offense. No applicant will be excluded from consideration due to prior arrests.

A photocopy of this release will be valid as an original, even though the said photocopy does not contain an original writing of my signature.

I have read and fully understand the contents of this "Authorization for Release of Personal Information."

Identify the state, county or counties in which you have lived over the past seven (7) years.

  
I have read and fully understand the contents of this.
Current County: State: Past County: State:
Past County: State: