1. Employer's Name:
Phone:
Job Title:
Address:
City:
State:
Zip:
Last Salary/Hourly Rate:
Hours per week:
Job Duties:
Supervisor's Name:
Phone Number:
Reason for Leaving:
Date Started Employment (Month and Year):
Date Ended Employment(Month and Year):
2. Employer's Name:
Phone:
Job Title:
Address:
City:
State:
Zip:
Last Salary/Hourly Rate:
Hours per week:
DUTIES:
Supervisor's Name:
Phone Number:
Reason for Leaving:
Date Started Employment (Month and Year):
Date Ended Employment(Month and Year):
3. Employer's Name:
Phone:
Job Title:
Address:
City:
State:
Zip:
Last Salary/Hourly Rate:
Hours per week:
DUTIES:
Supervisor's Name:
Phone Number:
Reason for Leaving:
Date Started Employment (Month and Year):
Date Ended Employment(Month and Year):
REFERENCES:
Professional References:
1. Name:
Occupation:
Address:
Phone:
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2. Name:
Occupation:
Address:
Phone:
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3. Name:
Occupation:
Address:
Phone:
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Personal References:
1. Name:
Address:
Phone:
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2. Name:
Address:
Phone:
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3. Name:
Address:
Phone:
Is additional information relative to change of name, assumed name or nickname necessary to enable a check of your references?
YES: NO:
If yes,
please explain:
GENERAL:
Have you previously applied for a position with Saratoga Bridges (formerly Saratoga ARC)?
YES: NO:
If yes, position?
Special Training;
* 1. Have you ever been convicted of a Misdemeanor or a Felony in any
Jurisdiction or do you have any pending criminal charges against you?
If yes, please explain date & nature of conviction or pending charge:
* 2. Have you ever been the Subject of an indicated report of Child Abuse or
Maltreatment?
* 3. Do you have a conviction or a history of Client or Child Abuse, Neglect
or Mistreatment
* Reference Inquiries Are Made To the State Central
Register
Offers of employment for positions requiring a driver's license are conditional and subject to a satisfactory license check.
* 4. Have you been convicted of any moving motor vehicle violations, including, but not limited to, alcohol and drug related offenses?
If yes, please identify:
*5. Have you had any suspension, revocation, DWI convictions, DWAI convictions, or any
occurrence involving harm to human beings or property while driving?
If yes, please explain:
*(NYS OMRDD REGULATION PART 681)
How did you find out about Employment opportunities with the
Saratoga Bridges?
Do you know anyone currently or formerly affiliated with Saratoga Bridges?
YES: NO:
If yes, as?
Are you 18 years old, or older?
YES: NO:
If not, state your age
(You will need to
provide a work permit if you are under 18 years of age)
Have you ever served in the U.S. Military?
YES: NO:
If yes, what branch?
If yes, please describe your current status and duties or special training:
BY SUBMITTING THIS APPLICATION, AND PLACING YOUR NAME IN THE SIGNATURE BOX, YOU ARE AGREEING TO THE
FOLLOWING:
In consideration of my employment, I agree to conform to the
rules and regulations of the Saratoga Bridges. My employment and
compensation can be terminated with or without cause and with or without
notice, at any time, at the option of either the Agency or myself. I
understand that an offer of employment is conditional pending a physical
examination, reference checks and, for positions requiring a driver's license,
a license check, all to the satisfaction of the Saratoga Bridges. Applicants who will have 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 for a criminal background check to be conducted. Saratoga Bridges applies this OMRDD regulation to all applicants.
If accepted for employment, I agree to submit myself for
examination by a physicial or physicians of the Agency's selection as often as
may be requested.
I certify that the information contained in this application
is correct to the best of my knowledge and understand that falsification of this information is grounds for dismissal in accordance with
Saratoga Bridges policy. I authorize the employers, schools and references
listed above to provide you with any and all information concerning my
previous employment and any pertinent infomation they may have, personal or
otherwise, and release all parties from all liability for any damage that may
result from furnishing same to you. If hired by Saratoga Bridges I authorize the release of my employment history and related records at Saratoga Bridges to potential future employers requesting such information. I release SARATOGA BRIDGES and its representatives from all liability for any damages incurred in providing this information.
Signature (Type Full Legal Name):
Date: