Madison Cortland Chapter, NYSARC, INC.

701 Lenox Ave., Oneida, NY 13421 (315) 363-3389

Application for Employment Please Print

16 Crawford St., Cortland, NY 13045 (607) 756-2015

Position(s) Applied for: Date of Application

Last Name First Name Middle Other Formal Names

Street Address City State Zip

Telephone Number(s) Home ( ) Work ( ) Cell ( )

E-mail address

Referral Source:

DOL Name Source if applicable:________________________________

Are you at least 18 years of age? Yes No

Yes No Have you ever filed an application with us before? If yes, date ___________________________

Are you related to an employee at The Arc of Madison Cortland? If yes, to whom ___________________________ What is your relationship? _________________________

Yes No

Yes No

Yes No

Are you currently employed?

May we contact your present employer?

Yes No

On what date would you be available to work? _______________________________

Type of employment desired? Full Time Part Time Relief Temporary

Are you available to work? Days Evenings Nights Weekends

Yes No

Yes No

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Friend Walk-InJob Fair

Employment AgencyRelativeOther

Have you ever been convicted of or pled guilty to a felony or misdemeanor? (A conviction does not automatically bar you from employment.) If yes, provide details.

Are you able to perform the essential functions of the job for which you are applying with or without reasonable accommodations?

Are you prevented from lawfully becoming employed in this country because of visa or immigration status?(Proof of citizenship or work authorization status will be required)

Website/Online

EDUCATIONAL BACKGROUNDSchool Name/Address Years

Completed Degree/Diploma Did You Graduate? Major/Minor

DRIVER’S LICENSE INFORMATION Do you have a valid drivers license? Yes No License type/class______________________

License ID#_________________ Expiration date _________________________ State where issued ______

Have you had your class D (or higher) driver’s license for 18 months or more? Yes No

Any moving traffic violations or convictions involving harm to persons or property while driving within the past eight (8) years? Yes No

Has your driver’s license ever been revoked or suspended? Yes No

Yes NoHave you had any convictions for an alcohol or drug related offense?An abstract of your driving history will be obtained, depending on position offered

PERSONAL REFERENCES List the name/address/telephone number for three personal references that are NOT related to you but may be contacted as part of the application process. If not applicable, list three school references that can attest to your character, reputation and personal qualifications.

Name Telephone # Years Known

List professional trade, business, civic activities, and offices held. You may exclude memberships that would reveal gender, race, religion, national origin, disability or other protected status:

Skills and Qualifications - Summarize any special training, skills, licenses, certificates, and/or characteristics of yourself that may qualify you as being able to perform job-related functions for the position for which you are applying.

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Address

EMPLOYMENT HISTORY List your last four (4) employers, assignments or volunteer activities, starting with the most recent, including military experience -or- attach a resume and list of professional references. Explain any gaps in employment in comment section below. Employer Telephone

( ) Dates Employed Summarize the nature of the work

performed and job responsibilities From To Address

Hourly Rate/Salary Job Title Start Final

Immediate Supervisor/Title

Reason for Leaving Contact as a Reference?

Yes No Employer Telephone

( ) Dates Employed Summarize the nature of the work

performed and job responsibilities From To Address

Hourly Rate/Salary Job Title Start Final

Immediate Supervisor/Title

Reason for Leaving Contact as a Reference?

Yes No Employer Telephone

( ) Dates Employed Summarize the nature of the work

performed and job responsibilities From To Address

Hourly Rate/Salary Job Title Start Final

Immediate Supervisor/Title

Reason for Leaving Contact as a Reference?

Yes No Employer Telephone

( ) Dates Employed Summarize the nature of the work

performed and job responsibilities From To Address

Hourly Rate/Salary Job Title Start Final

Immediate Supervisor/Title

Reason for Leaving Contact as a Reference?

Yes No

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Comments (including explanation of any gaps in employment):

APPLICANT'S STATEMENT I certify that the answers given herein are true and complete to the best of my knowledge.

I authorize investigation of all statements contained in the application for employment as may be necessary in arriving at an employment decision.

I hereby acknowledge that any employment relationship with The Arc of Madison Cortland requires a mutual commitment. Therefore, it can be terminated by myself or the Agency at any time and for any reason, without previous notice.

In the event of employment, I understand that providing false, or misleading information or the omission of information in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Agency/employer.

Signature of Applicant ______________________________ Date_____________

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This application for employment shall be considered active for a period of time not to exceed 1 year. Any applicant wishing to be considered for employment beyond this time should inquire whether or not applications are being accepted at that time.

The Arc of Madison Cortland is an equal opportunity employer. Candidates shall be selected without regard to age, race, color, gender, marital status, religion, national origin, disability, sexual orientation or genetic information.