Sunday, 27 September 2020

Employment Application

Qualified applicants are considered for all positions without regard to race, color, religion, gender, genectic disposistion, carrier status, domestic violance victim status, amnesty, national origin, age, marital or veteran status, disability, sexual orientation, or any other factors prohibited by law.
Job Posting Select Posting to Apply for: 
Referral Select Referral Method: 



Current Address


High School
Undergrad School
Grad School
Other School


Employment Information
 Days  Evenings  Overnights  Weekends  Holidays  Overtime  On-call
Please answer all of the following questions.
1) Are you legally permitted to work in the United States?
If you are under 18 years of age, can you provide required proof of your eligibility to work?
2) Are you 18 years of age or older?
If you are under 18 years of age. can you provide a certification of your eligibility to work as provided for by law?
3) Are you able to perform the essential functions of the position sought with or without reasonable accommodations? Specific questions about essential functions of positions should be directed to the Human Resources Department.
4) Have you previously been employed by this agency?
If yes, when and where?
5) Are you a military veteran?
6) Have you ever worked for this agency under a different name?
If yes, please explain.
7) Is additional information relative to change of name or use of a different name, assumed name, or nickname necessary to enable a check of your work records and background?
If yes, please explain.
8) Have you previously submitted an employment application?
If yes, when and for what position?
9) Do any of your friends or relatives, other than spouse, work here?
If yes, state name and relationship...


Are you currently employed?
May we contact this employer?
Most Recent Employer
Prior Employer
May we contact this employer?
Prior Employer
May we contact this employer?
Prior Employer
May we contact this employer?

Skills, etc

Driving Information, Criminal Background, Employee Skills
Have you ever been convicted of or pled guilty to a felony, misdemeanor, violation, or other crime (other than traffic violation)? A conviction is not an automatic bar from employment. Each case is considered and evaluated on its individual merits in relation to the duties and responsibilities of the position.
If yes, provide details
Have you ever been convicted of or pled guilty to a felony, misdemeanor, violation, or other crime (other than traffic violation)?
If yes, provide details
Have you ever been or are you currently the subject of an indicated child abuse or maltreatment report on file with the New York Statewide Central Register of Child Abuse and Maltreatment? (i.e., NYS Child Abuse Hotline)
If yes, provide details
Have you ever been sanctioned or otherwise disciplined by, or excluded from, the New York Medicaid Program, Medicare or any other state or federal government funded program?
If yes, provide details
Have you ever been investigated by, or subject to disciplinary proceeding by a professional licensure or disciplinary agency (such as the Office of Professional Discipline, the Office of Professional Medical Conduct, or the Department of Health), in New York or in any other state?
If yes, provide details




Applicant Statement
1. I certify that all the information which I have submitted on this form is a true and correct statement of the facts and answers required herein without omissions of any kind whatsoever. I understand that any omission, misrepresentation, and/or falsification of information contained in this application may constitute grounds for my dismissal. I also understand that I am required to abide by all rules and regulations of the agency and that I will be required to provide proof of employment eligibility at the time of employment.
2. I further agree that The Arc of Schuyler may contact all and any previous employers, schools, and references for full information except as stated otherwise on this form. By submitting this form, I hereby authorize and direct the employers. schools, or persons, as well as The Arc of Schuyler, from all liability for any damages whatsoever in providing this information to The Arc of Schuyler.
3. I understand that The Arc of Schuyler uses a pre-employment drug test as part of its hiring process and that any offer of employment will be contingent upon a negative drug screen. The pre-employment drug test will be given after an offer of employment is made but before the performance of any job duties. I understand that if I do not pass the screening process, the conditional offer of employment will be withdrawn and any employment relationship will cease.
4. I understand that if I am hired by The Arc of Schuyler in a position in which I will have regular and substantial unsupervised or unrestricted physical contact with people receiving services, I will need to provide information, statements, and fingerprints as per the background check requirements of the Office for People with Developmental Disabilities. I also understand that a background check will be conducted on all applicants through the Federal and New York State Medicaid Exclusion List database. I understand that as an applicant for employment, I may withdraw my request without prejudice at any time before my application is accepted or declined, regardless of whether my criminal history record information or Exclusion List data was reviewed. I understand that I have a right to obtain, review, and seek correction of my criminal history record information under regulation and procedures established by the New York State Division of Criminal Justice Services. I understand that, if I am hired, my employment will be provisional pending the results of a criminal background check, as required by law. I also confirm that if I have not truthfully and accurately listed all criminal convictions, including my status in terms of being qualified to bill Medicaid, as requested on my application, that any offer of employment will be withdrawn, or, if I am hired before the discrepancy is discovered, that I will be subject to termination by the agency.
5. This is not a contract of employment. Any individual who is hired may voluntarily leave employment and/or may be terminated by the agency at any time for any reason not prohibited by law. Any oral or written statements or promises to the contrary are hereby expressly disavowed, and should not be relied upon by any prospective or existing employee. Your social security number may be required to perform a pre-employment background check and will be required for payroll purposes if you hired.
Security Code
Security Code
I understand that by typing my name in the signature box below and submitting this application electronically, that I have not misrepresented myself in any way.*:
Date: 2020-09-27 23:01:15


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