| 1. Applicant Information |
Today's Date: |
*(MM-DD-YYYY) |
| First Name: |
* |
Middle Initial: |
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Last Name: |
* |
| Street Address: |
* |
Apartment/Unit #: |
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| City: |
* |
State: |
* |
Zip Code: |
* |
| Email Address: |
* |
Home phone: |
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Cell Phone: |
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| Social Security #: | * (no dashes) |
| Desired Position: |
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Desired Salary: |
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Shift Availability: |
Day Evening Night |
Have you ever worked for Anderson Center for Autism or Anderson School? Yes No * |
| If yes, when? |
| Are you a citizen of the U.S.: Yes No * |
| If no, are you authorized to work in the U.S.? Yes No |
| Did you attend school or were you ever employed by a name other than indicated above? Yes No * |
If yes, please specify:
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| How were you referred to Anderson Center for Autism? |
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Internet Newspaper Friend |
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Employee (Employee Name) |
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Other (Specify other source) |
Please list all relatives currently working at Anderson Center for Autism:
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2. Military Service
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| Branch: From: To: Dates must be in MM-DD-YYYY format. |
| Rank at Discharge: Type of Discharge: |
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3. Education
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| High School: * |
| From: * To: * (Dates must be in MM-DD-YYYY format.) |
Address:
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| Did you graduate or receive a GED? Yes No * |
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| College: |
| From: To: (Dates must be in MM-DD-YYYY format.) |
Address:
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| Did you graduate? Yes No |
| Degree: |
| |
| College: |
| From: To: (Dates must be in MM-DD-YYYY format.) |
Address:
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| Did you graduate? Yes No |
| Degree: |
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| Other Education: |
Address:
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| Languages Spoken: |
Licenses/Certifications:
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4. Current and Previous Employment
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| (list most current employment first) |
| Company: Phone: |
Address:
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| Supervisor: Job Title: |
| Starting Salary: Ending Salary: |
Responsibilities:
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| From: To: (Dates must be in MM-DD-YYYY format.) |
Reason For Leaving:
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Company: Phone: |
Address:
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| Supervisor: Job Title: |
| Starting Salary: Ending Salary: |
Responsibilities:
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| From: To: (Dates must be in MM-DD-YYYY format.) |
Reason For Leaving:
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Company: Phone: |
Address:
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| Supervisor: Job Title: |
| Starting Salary: Ending Salary: |
Responsibilities:
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| From: To: (Dates must be in MM-DD-YYYY format.) |
Reason For Leaving:
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| May we contact your current employer for a reference?: Yes No * |
| A complete job history is necessary for consideration of employment. |
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5. Personal References*
(other than relatives or former employees)
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| Full Name: Phone: Relationship: |
Address:
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City:
State: Zip: |
| Full Name: Phone: Relationship: |
Address:
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City:
State: Zip: |
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6. Driver's Certification
(as part of your job duties, you may be required to drive an agency vehicle.)
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| Do you have a license to drive a car? Yes No * |
| If yes specify which state: |
| Have you ever had a drivers license suspended? Yes No * |
If yes, please provide details:
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| Have you ever had a drivers license Revoked? Yes No * |
If yes, please provide details:
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| Have you ever had a D.W.I. / D.W.U.I. / D.W.A.I.? Yes No * |
If yes, please provide details:
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| Have you ever had an accident that has resulted in an injury to anyone or property damage?Yes No * |
If yes, please provide details:
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7. Background Screening
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| Section 424-a of the NYS Social Services law requires that persons applying for employment with Child Care agencies be cleared with the State Central Registry to determine if they are the subject of an indicated child abuse or maltreatment report. |
| Have you ever had an indicated (founded) case of child abuse, maltreatment, or neglect filed against you?Yes No * |
If yes, please provide details:
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| Please provide accurate and complete information in response to the following questions. This information will be taken into account in the employment process. Exclude only arrests without convictions. Please note that a criminal record will not necessarily disqualify you from employment. |
| Have you ever been convicted of a felony or misdemeanor? (Include military service conviction) Yes No * |
If yes, please provide explanation, disposition and dates convicted:
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| Do you currently have felony or misdemeanor charges pending? Yes No * |
If yes, please explain:
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8. Equal Employment Opportunity Statement
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| Anderson Center for Autism is committed to provide a diverse workforce by ensuring that discrimination barriers to equal employment opportunity and upward mobility do not exist here. Equal opportunity means employment, development and promotion of individuals without consideration of race, color, disability, religion, age, gender, marital status, national origin, sexual orientation, veteran status or citizenship status, unless there is a bona fide occupational requirement which excludes a person in one of these protected groups. |
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9. Affirmation Statement
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(a) All of the statements within this employment application are true to the best of my knowledge and may be investigated by Anderson Center for Autism. I understand that any false statement or willful omission in this application will cause rejection or dismissal and that my employment is contingent upon satisfactory references. I acknowledge that if offered a position with Anderson Center for Autism, I will be required to submit to a Drug Screening and a failed drug test may result in withdrawal of employment offer. Anderson Center for Autism is an at-will employer and has the right to terminate employment at anytime.
If submitting this form electronically please check the following box to acknowledge that you have read and understand the previous statement. You will be required to sign this application if called for an interview.
*I have read and understand section (a) of the Affirmation Statement. Date: * (MM-DD-YYYY)
(b) I, the undersigned, as part of this application for employment at Anderson Center for Autism, hereby authorize all companies, education institutions, persons, law enforcement agencies, military services, former employers, and other who may have data required by Anderson Center for Autism, to release information in their possesion which they may have about me for the sole and express purpose of verifying this application of employment, and I hereby release and waive any and all claims against the persons or companies so requested from any liability or responsibilityfor the consequences of the release of information requested by the Anderson Center for Autism.
If submitting this form electronically please check the following box to acknowledge that you have
read and understand the previous statement. You will be required to sign this application if called for
an interview.
* I have read and understand section (b) of the Affirmation Statement. Date: * (MM-DD-YYYY)
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