Name: ______________________________________________

Please read the following before completing our Employment Application ❖ Our application must be completely filled out in order for it to be considered for any vacancies. ❖ Your application will be considered unacceptable if the information provided on the application cannot be satisfactorily verified or is determined to be false information. ❖ Please be as specific as possible in stating the job you are applying for. However, we will consider your application for other positions, if you have the necessary qualifications. ❖ We will contact you if we wish you to come in for an interview. ❖ Due to the large number of applications we receive, it is not necessary to update your application unless you have experienced a change in address/contact or work history. Your application will be kept on file for one year. ❖ Should you be considered for employment, you will be subject to some or all of the following checks: • • • • • •

Employment Reference Checks from current and former employers Criminal Background Check Federal/State Fraud Exclusion Checks Pre-employment Testing Child Abuse Clearance Motor Vehicle Driving History

Please be aware that the Fair Credit Reporting Act covers the above checks and screenings. We do not investigate your personal credit history. We have attached a FAQ information sheet for your use. Thank you for your interest in our agency and the people we serve.

125 Cutler Pond Road Binghamton, NY 13905 phone: 607.723.8361 • fax: 607.723.8338

60 Lester Avenue Johnson City, NY 13790 phone: 607.797.8160 • fax: 607.797.8807

56 Broadway Owego, NY 13827 phone: 607.687.5140 • fax: 607.687.5179

E-mail: [email protected] • Website: www.achieveny.org

Achieve and Country Valley Industies 125 Cutler Pond Road Binghamton, New York 13905 Phone: (607) 723-8361 • Fax: (607) 723-8338

Applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital or veteran status, or the presence of a non-job related medical condition or handicap.

Personal Data – Please Print Name (Last, First, Middle)

Date

Mailing Address

City Telephone Home: (

State

Zip Social Security Number

)

Business: (

)

If you are under 18 years of age, can you provide required proof of your eligibility to work?

o Yes

o No

Are you prevented from lawfully becoming employed in this country because of Visa or Immigration status?

o Yes

o No

Are there any factors which would interfere with your performance of the position for which you are applying? If yes, please explain.

o Yes

o No

Have you previously been employed by this agency?

o Yes

o No

When?

Where?

Have you previously submitted an employment application?

o Yes

o No

When?

employment Data Position Applying For:

Wage or Salary Desired:

Are you available to work:

o Regular Full Time o Part Time o On Call Part Time o Intern o Summer o Volunteer o Temporary Willing to Work: (Check all acceptable)

o Day Shift o Evening Shift o Night Shift o Overtime o Call-In Basis o Weekends Are you currently working?

o No

When would you be available to work?

o Yes

Are you currently on “Lay-Off” status and subject to recall?

o No

o Yes

Can you travel if job requires it?

Work history

Start with your most recent position. Periods of unemployment should also be noted. Leave no gaps in time sequence. Include summer and cooperative education assignments. If additional space is required, please use a separate sheet. Company Name

From

Company Address

To



Mo. Yr. Mo. Yr.

Starting Base Salary Per Year

Type of Business

Final Is Base Salary Base Salary for Full or Per Year Part-Time Work?

Name of Immediate Supervisor

o Full Time

o Part Time

Starting Position Title Present/Last Position Title

Supervisor’s Title

Reason for Leaving Describe Duties and Responsibilities

May we contact this If no, when? employer now? o Yes o No Company Name

From

Employer’s Telephone No. (

Company Address

To



Mo. Yr. Mo. Yr.

Starting Base Salary Per Year

Type of Business

Final Is Base Salary Base Salary for Full or Per Year Part-Time Work?

Name of Immediate Supervisor

)

o Full Time

o Part Time

Starting Position Title Present/Last Position Title

Supervisor’s Title

Reason for Leaving Describe Duties and Responsibilities

May we contact this If no, when? employer now? o Yes o No Company Name

From

Employer’s Telephone No. (

To

Company Address

Mo. Yr. Mo. Yr.



Starting Base Salary Per Year

Type of Business

Final Is Base Salary Base Salary for Full or Per Year Part-Time Work?

Name of Immediate Supervisor

)

o Full Time

o Part Time

Starting Position Title Present/Last Position Title

Supervisor’s Title

Reason for Leaving Describe Duties and Responsibilities

May we contact this If no, when? employer now? o Yes o No

Employer’s Telephone No. (

)

Work history (continued) Include summer and cooperative education assignments. Periods of unemployment should also be noted. Leave no

gaps in time sequence. If additional space is required, please use a separate sheet. Company Name

From

To

Company Address

Mo. Yr. Mo. Yr.



Starting Base Salary Per Year

Type of Business

Final Is Base Salary Base Salary for Full or Per Year Part-Time Work?

Name of Immediate Supervisor

o Full Time

o Part Time

Starting Position Title Present/Last Position Title

Supervisor’s Title

Reason for Leaving Describe Duties and Responsibilities

May we contact this If no, when? employer now? o Yes o No

Employer’s Telephone No. (

)

Education and Training Please complete all applicable items, even if you have already submited a resume. Proof of education degree may be required. Type of School

If No, Graduated Credit Hrs. Major & Minor Type of Diploma, Complete Name and Address of School Yes No Completed Fields of Study Degree or Certificate

High School

Equivilency Diploma

Colleges

Universities Other Training (Including Military)

Course Source Class Hours

Military Service Branch

Entry Date

Date

Discharge Rank Duties

Completed o Yes o No

Present Status

professional Information Professional organization memberships (Exclude those which indicate race, religion, color or national origin.)

Professional Licenses

Special Skills and Qualifications Summarize special experiences, job-related skills and qualifications acquired from employment or other experience that would be beneficial to this agency.

References Give name, address, telephone number of three references who are not related to you and are not previous employers. 1. Name_ ____________________________________________________________________________________________

Address____________________________________________________________________________________________



Work Phone_______________________________________Home Phone_____________________________________

2. Name_ ____________________________________________________________________________________________

Address____________________________________________________________________________________________



Work Phone_______________________________________Home Phone_____________________________________

3. Name_ ____________________________________________________________________________________________

Address____________________________________________________________________________________________



Work Phone_______________________________________Home Phone_____________________________________

How did you learn about us? (Please check and specify name of referral source.) o Newspaper_____________________________________

o Friend_______________________________________

o Online Ad______________________________________

o Relative_____________________________________

o Walk-In_________________________________________ o Employment Agency ___________________________

Driver’s License Information Please be sure to complete the dirver’s license portion of the employment application, including any types of violations and/or problems. If you have not had any violations or problems, please write “None” on line of each category. If you do not have a drivers license, please state so and return the application to us. Driver’s License #_ _____________________________________________________________________________________ State of Issue __________________________ Class_________________________ Expiration Date__________________ Have you been licensed for at least three years? _________________ Address on License: _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ List all convictions in relation to moving violations within the last three (3) years. Type of Violation 1._ ____________________________________________________________________________________________________ 2._ ____________________________________________________________________________________________________ List any suspensions, revocation, DWI, or convictions in your driving history as well as any accident or occurrence involving harm to anyone or property while driving. Type of Problem

Date

1._ ____________________________________________________________________________________________________ 2._ ____________________________________________________________________________________________________

I, _______________________________________, hereby give my permission to ACHIEVE to verify the validity of my Driver’s License and driving record by contacting the Department of Motor Vehicles and/or other agencies authorized to provide driving related information. I understand and acknowledge that this validation is part of the pre-employment process and continues throughout my employment should I be hired. I further understand and acknowledge that the intent of this verification is to promote and ensure the safety of consumers, staff and other parties that I may be required to transport. It is also understood that ACHIEVE has a responsibility to inform me of any discrepancies which may result from this verification.

Signature

Date

ACHIEVE 125 Cutler Pond Road, Binghamton, NY 13905 CRIMINAL BACKGROUND CHECK REQUIREMENT

Name:_______________________________________________________________________________________________ 1. Have you ever been convicted of the following in any jurisdiction?

Misdemeanor: Yes_____

No_____

Felony: Yes_____

No_____

If yes, please provide description and explanation.

________________________________________________________________________________________________



________________________________________________________________________________________________



________________________________________________________________________________________________

2. Are there any pending criminal charges currently against you? Yes_____

No_____

If yes, please provide description and explanation.

________________________________________________________________________________________________



________________________________________________________________________________________________



________________________________________________________________________________________________

In conjunction with NYS OMRDD Part 633.5 Regulations, I understand that if I am being considered for hire by the Agency, I may have regular and substantial unsupervised or unrestricted physical contact with individuals with disabilities. That my employment is conditioned upon providing information, statements and fingerprints for the purpose of submitting my name, information and fingerprints to the Division of Criminal Justice Services of the State of New York for a report on my criminal history as required by Mental Hygiene Law Section 16.33 and 31.35. I also confirm that if I have not truthfully and accurately listed all criminal convictions and pending criminal charges as requested on my application, that any offer of employment can be withdrawn. Additionally, I am aware that I will be subject to termination by the agency if I am hired on a temporary and provisional basis before the discrepancy is discovered. I also understand that if I am a volunteer, or hired, or transferred to a position where I have the potential for regular and substantial contact with children that I am subject to and will complete a application to be submitted to the New York State Department of Social Services State Central Register of Child Abuse and Maltreatment to determine if there is an indicated report of child abuse or maltreatment. I understand that any offer of employment is temporary and provisional, pending the report form the State Central Register of Child Abuse and Maltreatment.

Signature

Date

EXCLUSION CHECK FORM It is the policy of NYSARC Inc., Broome-Tioga County Chapter (dba ACHIEVE) not to employ, contract with or otherwise do business with any individual or entity excluded from participation in federally sponsored health care programs, such as Medicare and Medicaid. See link to the HHS Office of Inspector General Exclusion Program for further explanation. http://oig.hhs.gov/fraud/exclusions/aboutexclusions.html Exclusion Check: An Exclusion Check is a search of (1) the U.S. Department of Health and Human Services, Office of Inspector General (“OIG”)’s List of Excluded Individuals/Entities (available on the OIG website at http://oig.hhs.gov/fraud/exclusions.asp); (2) the General Service Administration (“GSA”)’s Excluded Parties List System (available on the GSA website at http://www.epls.gov/); and (3) The New York State Medicaid Fraud or Program Integrity Issues website at http://www.nyhealth.gov/health_care/medicaid/fraud/listing.htm to determine if an individual or entity’s name appears on either list. Ineligible Person: For purposes of this Policy, an Ineligible Person is an individual or entity that is listed on the OIG’s List of Excluded Individuals/Entities, the GSA’s Excluded Parties List System and/or NYS Medicaid Fraud or Program Integrity Issues System. To assure compliance with this policy and the NYSARC, Inc. Corporate Compliance directive, NYSARC, Inc., Broome-Tioga County Chapter (dba ACHIEVE) requests all applicants and employees to undergo exclusion verification. If hired, the exclusion verification will be conducted on an annual basis to assure continued eligibility. In addition, NYSARC Inc., Broome-Tioga County Chapter (dba ACHIEVE) shall maintain supporting documentation for its exclusion checks and produce copies of such documentation to the HHS Office of Inspector General Exclusion Program upon request. Your signature below verifies your knowledge of this background check. Signature _________________________________________________________________

Date ___________________

I certify that all of the information that I have supplied on this employment application is a true and complete statement of the facts and answers required herein without omissions of any kind whatsoever. In the event of my employment, I understand that any omission, misrepresentation and/or falsification of information contained in this application may constitute grounds for my dismissal. I also understand that I am required to abide by all rules and policies of the Agency and that I will be required to provide proof of citizenship or employment eligibility at the time of employment. I further agree that ACHIEVE may contact all and any previous employers, schools and references for full information except as I have stated otherwise on this employment application. By this employment application and by signature below, I hereby authorize and direct the employers, schools, or persons named to give any information regarding my employment, education or character statements and hereby release said employers, schools, or persons as well as ACHIEVE from all liability for any damages whatsoever in providing this information to ACHIEVE. I understand that the Agency maintains an Alcohol and Controlled Substance Policy and that the policy requires that any employment offer made to me by the Agency will be contingent on my submitting to an alcohol and drug test and have a negative test result for pre-employment testing and throughout my employment if hired. This is not a contract of employment. Any individual who is hired may voluntarily leave employment at any time, and may be terminated by the Agency at any time. Any oral or written statements or promises to the contrary are hereby expressly disavowed, and should not be relied upon by any prospective or existing employee. I HAVE CAREFULLY READ AND UNDERSTAND THE ABOVE STATEMENTS. Applicant’s Signature______________________________________________________

Date ___________________