EMPLOYMENT APPLICATION

AN EQUAL OPPORTUNITY EMPLOYER

 

All qualified applicants are considered for positions without regard to race, ethnicity, color, sex, age, disability, sexual orientation, national origin, religion, creed, citizenship, marital status, veteran status, & family status. Please be reminded that this is just a preliminary application; and upon selection you will be required to complete other forms physically on site.

 

All questions must be answered carefully and completely

 

Position Desired Date Available      
How were you referred to the Agency? Advertising:      
  Agency:      
  Employee:      
  Other:      

PERSONAL INFORMATION

First Name:      
  Last Name:      
  Email:      
  Address      
  Street      
  City      
  State      
  ZipCode      
  Status        
  Citizen or Legal Alien with the right to work in the job for which you are applying



     
  Current Phone Numbers      
  Cell Phone #      
  Home Phone #      
  Are you 18 years or older?



     
  Do you have a Driver's License?



     

 

For a position for which driving is required, please list those convictions related to moving violations within the last three (y3) years;
suspension, revocation, DWI convictions, or any occurance involving harm to anyone or property while driving.

Please describe each incident in detail including dates of all convictions, suspensions, revocations.
Have you had any prior to current experience as an employee, volunteer, or certified provider with OPWDD; or any other state agency,

    YES NO      

Please provide the names, addresses, and telephone numbers of at least two (2) references who can verify each experience.

PROF REF NAME PROF REF ADDRESS PROF REF PHONE NUMBER

 

CRIMINAL RECORD

Have you ever been convicted of or are you awaiting a trial disposition on a felony, misdemeanor or summary offense in any
jurisdiction and/or do you have any pending criminal charges, arrests, or criminal accusations against you?

 

   



     

 

 

Cerebral Palsy of Westchester will check all applicant records prior to hire for criminal convictions.
CONVICTIONS WILL NOT AUTOMATICALLY DISQUALIFY JOB CANDIDATES . DATES OF CONVICTION & SERVICE WILL BE CONSIDERED.
Please be advised that you will need to provide information, statements and fingerprints according to the requirements of the agency and OPWDD/SED
OCFS order for a criminal background check to be conducted through DCJS. Also, you will have the right to obtain, review and seek correction of any
information received in response to the criminal background check conducted by DCJS.

 

TWO (2) PERSONAL RFERENCES (May not be a relative)

PERSONAL NAME PERSONAL ADDRESS PERSONAL PHONE NUMBER

 

EDUCATION

NAME AND ADDRESS GRADUATED  

Graduated Type of Degree, Dipolma or
Colleges or Universitites
Certificate & Major/Minor

 

HIGH SCHOOL    
VOCATIONAL SCHOOLS    
COLLEGE OR UNIVERSITIES    

 

 

OTHER RELATED HISTORY/ACTIVITIES

State Professional licenses held and where registered

List volunteer experience
List any other special training or skills you have or any courses you have taken that relate to the type of services in our agency

 

EMPLOYMENT HISTORY

 

FROM TO

EMPLOYER 1

ADDRESS

PHONE NUMBER

 

POSITION

SUPERVISOR

SALARY

 

JOB DUTIES

REASON FOR LEAVING

   

FROM TO

EMPLOYER 2

ADDRESS

PHONE NUMBER

 

POSITION

SUPERVISOR

SALARY

 

JOB DUTIES

REASON FOR LEAVING

   

FROM TO

EMPLOYER 3

ADDRESS

PHONE NUMBER

 

POSITION

SUPERVISOR

SALARY

 

JOB DUTIES

REASON FOR LEAVING

   

 

Cerebral Palsy of Westchester may conduct investigations, including but not limited to those relating to prior employment history record of convictions, pending trial status, and driving records. I understand that it is the policy of Cerebral Palsy of Westchester to endeavor to provide the maximum protection and safety for those persons receiving services from the agency and I will need to provide information, statements, and fingerprints pursuant of the agencies requirements and OPWDD regulations in order for a criminal background check to be conducted through DCJS. It is the policy of DCJS that upon completion of the criminal backgroundcheck, I will be informed of the procedures necessary to obtain, review, seek correction of my criminal record.
I certifiy that all information and responses I have provided in this application are true. I authorize Cerebral Palsy of Westchester to investigate all my responses herein for accuracy and completeness and grant Cerebral Palsy of Westchester my premission to investigate all prior employment and all professional, military and educational records. I understand that any false or misleading statements, or omissions, made by me on this application or in connection with my physical false statements are discovered by the agency examination will render this application void and be sufficient grounds for dismissal, regardless of when such omissions or after my employment. I fully understand that this application is not a contract of employment and that employment with Cerebral Palsy of Westchester is at-will and may be terminated for any or no reason at either my option or the Agency's option at anytime. I also understand that any employment offer is dependent upon my satisfactory completion of the required three (3) month introductory period. I agree, if employed to follow all the Agency's rules and regulations.