Employment Form

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Personal Information

Date(Required)

MM slash DD slash YYYY

Your Name(Required)

First Middle Initial Last

Present Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email Address(Required)

Enter Email Confirm Email

Are you legally eligible for employment in the USA?(Required)

Are you over the age of 18?(Required)

Do you have a valid NYS driver’s license?(Required)

Telephone No.(Required)

Position applying for:(Required)

Rate of pay expected per week

Would you work:

Full Time

Part Time

Specify days and shift preferred

If checked Specify days and shift preferred:

Were you previously employed by us?(Required)

If yes, when?

Who referred you?

List any relatives or friends working for us:(Required)

List any relatives or friends living with us:(Required)

If your application is considered favorably, on what date will you be available to start work?

Are there any other experiences, skills or qualifications you feel would benefit you for work with our organization?

Record of Education

High School(Required)

Name and Address

Check Last Year Completed(Required)

Course of Study

Did you Graduate?(Required)

Yes

List Diploma or Degree

College

Name and Address

Check Last Year Completed

Course of Study

Did you Graduate?

Yes

List Diploma or Degree

Other

Name and Address

Check Last Year Completed

Course of Study

Did you Graduate?

Yes

List Diploma or Degree

Previous Employment

List below all present and past employment, beginning with your most recent employer.

Your Previous Employers(Required)

Employer

Address

Dates

Position

Phone

Reason for Leaving

Supervisor and Title

Your Previous Employers

Employer

Address

Dates

Position

Phone

Reason for Leaving

Supervisor and Title

Your Previous Employers

Employer

Address

Dates

Position

Phone

Reason for Leaving

Supervisor and Title

When can we contact the employers listed above?(Required)

Immediately

Upon a conditional offer of employment

3 Personal References (All 3 Required)(Required)

(Do Not List Former Employers or Relatives - Teachers or Previous Co-workers preferred)

Name

Complete Email or Mailing Address

Phone Number

(Required)

Name

Complete Email or Mailing Address

Phone Number

(Required)

Name

Complete Email or Mailing Address

Phone Number

Cardinal Hayes Home

Milbrook, NY

BACKGROUND SCREENINGS

Employment may require clearance through OPWDD’s Criminal Background Check Unit, SEL, MHL 16.34 Statewide Central Registry, and others as required by New York State OPWDD and the Justice Center. Convictions and/or allegations do not automatically disqualify your from employment. Failure to disclose information or misrepresentations will be considered falsification of this application.

Have you ever been the subject of an indicated case of child abuse and maltreatment or convicted of sexual misconduct in any state?(Required)

Yes

If yes, please explain:

Have you ever been convicted of a misdemeanor or felony in any jurisdiction?(Required)

Yes

If yes, please explain:

Do you have any criminal charges pending?(Required)

Yes

If yes, please explain:

Have you been convicted of a moving violation within the last 3 years (including, but not limited to convictions involving alcohol and/or drugs while driving)?(Required)

Yes

Has your license even been suspended or revoked?(Required)

Yes

Have you been involved in a motor vehicle accident or occurrence involving harm to anyone or property while driving? (Please note harm to property can be as minor as hitting a guard rail or a street sign, another vehicle, minor accident, etc.)(Required)

Yes

If yes, describe in full:

In a short paragraph, briefly tell us why you are interested in working with individuals with developmental disabilities.

PLEASE AGREE TO THE FOLLOWING TERMS(Required)

The facts set forth in my application for employment are true and complete. I understand that if employed, false statements on this application shall be considered sufficient cause for dismissal. You are hereby authorized to make any investigation of my personal history, financial and credit record through any investigative or credit agencies or bureaus of your choice.
In making this application for employment, I authorize you to make an investigative consumer report whereby information is obtained through personal interviews with my neighbors, friends, or others with whom I am acquainted. This inquiry, if made, may include information as to my character, general reputation and personal characteristics.
I understand that my employment will be based upon the outcome of background checks, successful completion of the agency’s orientation process and all reference checks. I am considered a temporary/provisional employee until the above is satisfied.

I agree to the terms and conditions.

Untitled

Cardinal Hayes Home for Children

Employment Form

Cardinal Hayes Home for Children Application

Personal Information

Record of Education

Previous Employment

Cardinal Hayes Home

BACKGROUND SCREENINGS