NY Job Application Form

I. PERSONAL

Last Name(*)
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First Name/Middle Initial(*)
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Street Address(*)
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City(*)
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State(*)
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Zip(*)
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Home Telephone(*)
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Business Telephone
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Are you over 18 years of age? (*)
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Type of Position Desired(*)
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Salary Desired(*)
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How were you referred? (*)

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Please check one of the following

Newspaper Which one?
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Job Fair, which college:
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Other, Please indicate:
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Were you referred by a CFS employee?
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If yes, name of employee
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What areas are you available to work in (Check):(*)

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What hours are you available to work?(*)
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When can you begin work?(*)
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What days are you available to work?(*)

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(*)
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Have you ever been convicted of, or pleaded guilty to, a criminal offense including felonies, misdemeanors and violations (excluding traffic infractions) in any jurisdiction?

(Do not include information regarding convictions that have been expunged, sealed or impounded.)(*)
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If your answer is "Yes," please state the crime for which you were convicted (or pleaded guilty) as well as the date and location of the conviction.

(Please explain any affirmative (i.e., "yes") answer so that individual circumstances can be considered. Use an additional sheet of paper, if necessary.)(*)
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A criminal record will not necessarily be a bar to employment. A conviction only will be considered as it may relate to the job you are seeking at The Center for Family Support. Factors such as the seriousness and nature of the offense, the date of the conviction and your age at the time, and subsequent rehabilitation will be taken into consideration.

Are there any criminal charges currently pending against you?(*)
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(Note: A conviction will not necessarily be a bar to employment. Factors such as age at the time of offense, seriousness of the offense and rehabilitation will be taken into account.)

Any applicant having regular and substantial unsupervised or unrestricted physical contact with people receiving services, will need to provide information, statements, and fingerprints according to the requirements of OMRDD regulations in order for a criminal background check to be conducted.
(*)
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Do you have any friends or relatives or do you know anyone that works at CFS?

If yes, please state their names and explain the relationship:(*)
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(*)
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Do you have a valid New York or New Jersey drivers license with a clean driving record?

If not please Explain:(*)
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(*)
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Are you able to perform the essential functions of the job for which you are applying, with or without reasonable accommodation?

If no please explain:(*)
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II. EDUCATION

Last school attended:(*)

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School Name(*)
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Address(*)
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Course of study(*)
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Degree(*)
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Dates attended(*)
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School Name
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Address
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Course of study
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Degree
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Dates attended
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School Name
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Address
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Course of study
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Degree
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Dates attended
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Do you have other training, certification, or volunteer experience relevant to the position for which you are applying?

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Other:
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III. EMPLOYMENT HISTORY

Please give an accurate, complete employment record. Start with your present or most recent employer.

Company Name(*)
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Dates Employed(*)
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Street Address(*)
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City(*)
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State(*)
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Zip(*)
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Salary(*)
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Start(*)
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Last(*)
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Name of Supervisor(*)
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Phone(*)
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State job title and describe your work(*)
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State reason for leaving(*)
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Company Name
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Dates Employed
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Street Address
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City
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State
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Zip
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Salary
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Start
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Last
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Name of Supervisor
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Phone
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State job title and describe your work
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State reason for leaving
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References: Applicants are to furnish two personal references below.
Name(*)
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Address
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Street

City
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State
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Zip
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Phone(*)
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Name(*)
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Address
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Street

City
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State
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Zip
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Phone(*)
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(*)
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The information provided in this Application for Employment is correct and complete. Any misstatement (untrue statements) or omission of fact on this application will result in my dismissal. I understand that acceptance of an offer of employment does not create a contractual obligation upon The Center for Family Support to continue to employ me in the future.

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It is the policy of The Center for Family Support that no individual will be hired who has a history of client/child abuse, mistreatment or neglect. Section 424-a of the New York State Social Services Law requires this agency, as a provider of services for children in residential or non-residential facilities operated or certified by the Office of Mental Retardation and Developmental Disabilities (OMRDD), to inquire whether anyone actively considered for employment who will have the potential for regular and substantial contact with children being cared for by the agency is the subject of an indicated report of child abuse or maltreatment on file with the State Central Register of Child Abuse and Maltreatment (Office of Children and Family Services). I understand that my name will be submitted to the New York State Department of Social Services in order for The Center for Family Support to check my background. Please indicate if you have been a subject of child abuse or maltreatment case. I understand that any indication of an omission of fact could result in termination. (Please Explain)