APPLICATION FOR EMPLOYMENT
Personnel are chosen on the basis of ability without regard to race, color, religion, sex, age, national origin, disability, marital
status, military status, sexual orientation, citizenship or any other protected classification in accordance with federal and state
law.
Name (Last)
(First)
(Middle Initial)
Address (Street)
(City)
(State)
(Zip)
Home Phone
Date: _____________________
EMPLOYMENT INFORMATION
Position(s) applied for: _____________________________________________________________________
Location: __________________________
Status desired:
Full Time
Would you consider employment at another location?
Part Time
Substitute
__________
Temporary
The following conditions may be required at some point in a job assignment:
If required, would you be willing to work:
Shift work?
Work scheduled other than Monday through Friday?
Do you have reliable transportation?
Yes
No
Yes
No
______________
How did you learn about this position?
Overtime work?
Yes
No
Date available: ____________
___________________________________________________________
GENERAL INFORMATION
Please check the appropriate information:
Are you:  18 or under? (If under 18, indicate age ________)
Do you have a valid New York State Driver’s License?
Yes
No
Out of state license
Have you ever applied to AHRC before?
Yes
No
If yes, give date ________________
Have you ever worked or volunteered at AHRC before?
Yes
No
If yes, give date ________________
Are you employed now?
Yes
No
Are you related to anyone who currently works for AHRC?
Yes
No
If yes, whom
Yes
No
__________________
EMPLOYMENT EXPERIENCE
Please list your employment experience. Include US Military experience, summer and or part-time jobs and cooperative education assignments. List your most
recent employment first. (Be sure to list prior experience with any NYS agency or any direct care experience relevant to the position for which you are applying).
Company Name: ______________________________________________________________
Address
(Street)
(City)
Employed from: ______________ to: ____________________
Phone_____________________________
(State)
(ZIP)
Rate of pay: start: _______________ final: ___________________
Position title and description of duties: __________________________________________________________________________________
Name of supervisor: _________________________________ Reason for leaving: ______________________________________________
Company Name: ______________________________________________________________
Address
(Street)
(City)
Employed from: ______________ to: ____________________
Phone_____________________________
(State)
(ZIP)
Rate of pay: start: _______________ final: ___________________
Position title and description of duties: __________________________________________________________________________________
Name of supervisor: _________________________________ Reason for leaving: ______________________________________________
Company Name: ______________________________________________________________
Address
(Street)
(City)
Employed from: ______________ to: ____________________
Phone_____________________________
(State)
(ZIP)
Rate of pay: start: _______________ final: ___________________
Position title and description of duties: __________________________________________________________________________________
Name of supervisor: _________________________________ Reason for leaving: ______________________________________________
Company Name: ______________________________________________________________
Address
(Street)
(City)
Employed from: ______________ to: ____________________
Phone_____________________________
(State)
(ZIP)
Rate of pay: start: _______________ final: ___________________
Position title and description of duties: __________________________________________________________________________________
Name of supervisor: _________________________________ Reason for leaving: ______________________________________________
========================================================================================
May we contact your present employer to verify the above?
 Yes, you may contact at any time.
Do not contact now; you may contact after the following date ______________________________________________
Area code and phone number:_______________________________________________________________________________________________________
EDUCATION AND TRAINING
Name and Address of School
Graduated?
Yes or No
Type of Degree, Diploma or
Certificate & Major/Minor Fields
of Study
Last High School
Attended
Vocational, Tech School
Or Junior College
College/University
Other Training, Skills, Licenses, or Certifications: __________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Academic/Professional Achievements and Activities: ______________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Please briefly state your reason for applying for this position:________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
______________________________________________________________________________________________________________
Personal References (not former employers or relatives)
Area code and phone number
1. ___________________________________________________________________________________
_____________________________________________________________________________________
2. ___________________________________________________________________________________
_____________________________________________________________________________________
Personal Background Information
Please answer the following questions. Note that none of the circumstances represent an automatic ban on employment.
Each case is considered and evaluated on individual merits in relation to duties and responsibilities of the position(s) for
which you are applying.
1. Were you ever dismissed or discharged from any employment for reasons other than
lack of work or funds?
Yes
No
2. If applying for a position requiring a professional license or certificate, were you ever disciplined by
a governmental or sanctioning agency responsible for issuing or monitoring licenses or certificates?
Yes
No
3. If you are applying for a position which requires driving (Driver, Residential Support Worker,
Residential etc.), have you had any motor vehicle moving violations, suspensions, DWI convictions,
revocation of your driver’s license, or any occurrence involving harm to anyone or property within
the last three years?
Yes
No
4. Did you ever resign from any employment rather than face dismissal?
Yes
No
5. Have you ever been convicted of a crime (felony or misdemeanor)?
(Criminal background checks may be made on anyone hired for
positions which involve contact with consumers)
Yes
No
6. Have you ever been known by another name?
7.
Yes
No
If yes, what name? _____________________________
Are you now under charges for any crime?
Yes
No
Please explain any questions answered, “Yes”:
_____________________________________________________________________________________
_____________________________________________________________________________________
Applicant’s Statement
I authorize the persons, schools, current employers (if approved by me in the Employment Experience Section) and other
organizations or employers named in this application to provide Orange AHRC with any relevant Information that may be
required to arrive at an employment decision.
I hereby declare that the preceding information is true and correct to the best of my knowledge. I understand that falsification of
statements, misstatements or omissions of fact on this application will be considered a cause for dismissal.
If I am hired for a position requiring a criminal background check, I authorize Orange AHRC to conduct such a check.
Signature: _____________________________________________
Date: ______________________
ORANGE AHRC THANKS YOU FOR YOUR INTEREST AND RESPONSE