Referral Source (Please indicate referral source)
NewspaperEmployeeEmployment AgencyOn-Line AdvertisementAgency Web SiteRelativeBillboardJob FairIndeed.comCraigslist.orgMonster.comRadioTVFriendWalk-inOther
Name:
Maiden Name:
Home Address:
Telephone Number(s)
Home:
Cell:
Email Address:

Are you at least 18 years of age?
YesNo
Have you ever filed an application with us before?
YesNo
If yes, give date:
Are you related to an Arc employee?
YesNo
If yes, to whom:
What is your relationship?
Are you currently employed?
YesNo
May we contact your present employer?
YesNoN/A
Are you legally authorized to work in the United States?
YesNo
Will you now or in the future require sponsorship for employment visa status (e.g., H-1B, TN, etc.)?
YesNo
On what date would you be available to work?
Type of employment desired?
Full TimePart TimeReliefTemporary
Are you currently on "lay-off" status and subject to recall?
YesNo
Has an employer ever determined that you abused, neglected, or mistreated a child or adult in your care?
YesNo
Have you ever been disciplined by an employer for abusing, neglecting, or mistreating a child or adult in your care?
YesNo
Have you been placed on any federal or state list of excluded individuals, such as the List of Excluded Individuals (LEIE) maintained by the Office of the Inspector General of the U.S. Department of Health and Human Services, the Medicaid exclusion list maintained by the state Office of the Medicaid Inspector General, or the NYS Justice Center Staff Exclusion List?
YesNo
Are you able to perform the essential functions of the job for which you are applying with or without a reasonable accommodation?
YesNo


Employment History

List your last four(4) employers, assignments or volunteer activities, starting with the most recent, including military experience. Explain any gaps in employment in comments section below.

Employer #1
Name:

Telephone:

Address:





Job Title:

Immediate Supervisor/Title:

Reason for Leaving:
Dates Employed:
From:
To:
Hourly Rate/Salary:
Starting:
Final:
Summarize the nature of the work performed and job responsibilities:
Employer #2
Name:

Telephone:

Address:





Job Title:

Immediate Supervisor/Title:

Reason for Leaving:
Dates Employed:
From:
To:
Hourly Rate/Salary:
Starting:
Final:
Summarize the nature of the work performed and job responsibilities:
Employer #3
Name:

Telephone:

Address:





Job Title:

Immediate Supervisor/Title:

Reason for Leaving:
Dates Employed:
From:
To:
Hourly Rate/Salary:
Starting:
Final:
Summarize the nature of the work performed and job responsibilities:
Employer #4
Name:

Telephone:

Address:





Job Title:

Immediate Supervisor/Title:

Reason for Leaving:
Dates Employed:
From:
To:
Hourly Rate/Salary:
Starting:
Final:
Summarize the nature of the work performed and job responsibilities:
Comments (including explanation of any gaps in employment):

Educational Background

Must be accredited by the Department of Education in the state in which it was issued

High School
Name:

Address:




Years Completed:

Did you Graduate?
YesNo
Degree:
GEDDiploma
College / University
Name:

Address:




Years Completed:

Did you Graduate?
YesNoN/A
Degree:
Graduate/Professional
Name:

Address:




Years Completed:

Did you Graduate?
YesNoN/A
Degree:

Driver's License Information

(If the position you are applying for requires a Driver's License, please be sure to complete this section)
Do you have a valid NY State driver’s license? YesNo
License (type/class):

License I.D.#:

Date Issued:

Expiration Date:

State where issued:

Personal References

List three school or personal references who are not related to you.

Reference 1
Name:

Address:




Telephone:

Years Known:

Relationship:
Reference 2
Name:

Address:




Telephone:

Years Known:

Relationship:
Reference 3
Name:

Address:




Telephone:

Years Known:

Relationship:
List professional, trade, business, civic activities and offices held.
You may exclude memberships which would reveal sex, race, religion, national origin, ancestry, handicap 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.

Applicant's Statement

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

I authorize and will cooperate with an investigation of all statements contained in my application for employment as may be deemed necessary by The Arc, Oneida-Lewis Chapter, NYSARC including: criminal background checks to include finger print review, exclusion checks, reference checks, and past employment history as well as all other matters which may be authorized and/or required by law.

This application for employment shall be considered active for a period of time not to exceed 2 years. Any applicant wishing to be considered for employment beyond this time should inquire whether or not applications are being accepted at that time.

I hereby acknowledge that any employment relationship with The Arc, Oneida-Lewis Chapter, NYSARC is of an “at will” nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood this “at will” employment relationship may not be changed by
conduct or any written document unless such document is in writing and authorized by the Executive Director of The Arc, Oneida-Lewis Chapter, NYSARC.

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

All offers of employment will be made subject to the results of a drug test. A federally certified drug-testing laboratory will provide drug-testing services. The process will ensure individual privacy during the collection process and the confidentiality of test results. Any applicant with a confirmed positive test result will be denied employment. The Arc will not discriminate against applicants for employment because of past drug use prior to 90 days.

Name:

Date:

Criminal History Background Check

The Arc, Oneida-Lewis Chapter, NYSARC is required by Chapter 575 of the Laws of 2004, New York State Office for People With Developmental Disabilities (OPWDD) and Office of Mental Health (OMH) to obtain Criminal History Background Checks.

Prospective employees, operators and volunteers will be fingerprinted and criminal history checks will be obtained from the New York State Division of Criminal Justice Services (DCJS) before assuming duty involving regular and substantial unsupervised or unrestricted physical contact with person’s receiving services.

I further understand that if the position I am applying for allows me regular and substantial unsupervised or unrestricted physical contact with people receiving services, I agree to provide information statements and
fingerprints according to the requirements of the Office of Mental Health and/or the OPWDD regulations in order for a criminal background check to be conducted. I understand that any false answers to any question in the application process will be grounds for immediate dismissal.

The Arc, Oneida-Lewis Chapter, NYSARC is required to screen prospective employees and check the information against the List of Excluded Individuals (LEIE) maintained by the Office of the Inspector General of the U.S. Department of Health and Human Services, the Medicaid exclusion list maintained by the state Office of the Medicaid Inspector General, and the New York State Justice Center Staff Exclusion List.

In order to be considered for employment you must answer the following questions:

Have you ever been convicted of a misdemeanor or a felony in any jurisdiction?
YesNo

Are you now under pending investigation or have any pending charges of violation of criminal law, to include misdemeanors or felonies?
YesNo

If yes, describe all convictions and pending charges:

Have you been the subject of any adverse action(s) by any duly authorized sanctioning or disciplinary agency for either conduct based or performance based actions?
YesNo

If yes, explain:

Name:

Date:

Voluntary Self ID of Disability Form (CC-305)

Due to the fact that we do business with the government, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities. To help us measure how well we are doing, we are asking you to tell us if you have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will choose to fill it out. If you are applying for a job, any answer you give will be kept private and will not be used against you in any way. If you already work for us, your answer will not be used against you in any way.

Since a person may become disabled at any time, we are required to ask all of our employees to update their information every five years. You may voluntarily self-identify as having a disability on this form without fear of any punishment because you did not identify as having a disability earlier.

What is a Disability?

You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition.

Disabilities include, but are not limited to:

Blindness, Autism, Bipolar disorder, Post traumatic stress disorder (PTSD), Deafness, Cerebral palsy, Major depression, Obsessive compulsive disorder, Cancer, HIV/AIDS, Multiple scelerosis (MS), Impairments requiring the use of a wheelchair, Diabetes, Schizophrenia, Missing limbs or partially missing limbs, Intellectual disability (previously called mental retardation), Epilepsy, Muscular dystrophy

Please check one of the boxes below:
Yes, I have a disability (or previously had a disability)No, I don't have a disabilityI don't wish to answer

Name:

Date:

Reasonable Accommodation Notice
Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of reasonable accommodation include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment.

Affirmative Action Voluntary Information

(Completion of information below is voluntary)

We consider applicants for all positions without regard to race, color, religion, sex, national origin, age, disability, veteran status or any other legal protected status.

To be completed by applicant. Not for interview purposes to be filed separately from application. This information is used to satisfy the Affirmative Action requirements of Section 503 of the Rehabilitation Act or necessitated by another federal law or regulation. As required, we comply with government regulations including Affirmative Action obligations where they apply.

In an effort to comply with requirements regarding government recordkeeping, reporting and other legal obligations, we ask that you complete this applicant data survey. Your cooperation is appreciated.

Please be advised that this survey is NOT a part of your official application for employment. It is considered confidential information that will not be used in any hiring decision.

Applicant Information
Name:

Telephone:

Address:



Sex:
MaleFemale

Email:

Please check one of the following Equal Opportunity Identification Groups:
American Indian/Alaskan NativeBlack or African AmericanHispanic or LatinoAsian not Hispanic or LatinoNative Hawaiin/Pacific IslanderWhite not Hispanic or LatinoTwo or more races

If you so wish to be identified, please check if any of the following are applicable:
Vietnam Era VeteranWounded Warriors (after 9/10/2001)Disabled veteranIndividual with a disability

Position(s) applied for:

Date:

Referral Source (How did you hear about the position?):
NewspaperEmployeeEmployment AgencyOn-Line AdvertisementAgency Web SiteRelativeBillboardJob FairIndeed.comCraigslist.orgMonster.comRadioTVFriendWalk-inOther

Please check the appropriate answer below.
Are you a veteran?
YesNo