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PART B JOB APPLICATION

PART B - Application for Employment
First Name *
Middle
Last Name *
Which County is the position in?

Section I

Do any relatives work here?

Section II

Are your work records under another name/names?
May we contact your present employer?
Do you have a history of abuse on file in the OPWDD, OMH OR DOH system?

Section IV

Education
Did You Graduate?
Did You Graduate

Section V

Employment Experience
Start Date
–
End Date
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Employment Experience
Start Date
–
End Date
ext Extension
List any other experiences, skills, qualifications, professional licenses you believe will be beneficial in considering your application.

Section VII

Personal References
List two names, NOT former employers or relatives
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First Name *
Last Name *
ext Extension
Country
Address Line 1
City
State/Province
Postal Code
First Name *
Last Name *
ext Extension
Country
Address Line 1
City
State/Province
Postal Code
No file selected
No file selected

Applicant Authorizations

"The Arc does not discriminate in employment on the basis of race, color, religion, sex (including pregnancy and gender identity), national origin, political affiliation.
Please check box to confirm you have read this non-discrimination statement
"The Arc does not discriminate in employment on the basis of sexual orientation, marital status, disability, genetic information, age, membership in an employee organization, retaliation, parental status, military service, or other non-merit factor.”
Please check box to confirm you have read this non-discrimination statement

Please read and sign

I affirm that the facts set forth in my application are true and complete. I understand that if employed, any omission of facts or false statement on this application may result in my dismissal.
Please check box to confirm that you read the above statement
I further understand that this application is not, and is not intended to be, а contract of employment nor does this application obligate the employer in any way if the employer decides to employ me.
Please check box to confirm that you read the above statement
I understand and agree that my employment is at-will and can be terminated by either party without notice, at any time, for any reason or no reason.
Please check box to confirm that you read the above statement
No one other than an officer of the agency has any authority to enter into any agreement for any employment for any specific period of time or to make any agreement contrary to the foregoing and then only in a written signed statement by an officer.
Please check box to confirm that you read the above statement
I authorize The Arc Greater Hudson Valley to make inquiries and investigations of my person, employment history and other related matters as may be necessary in arriving at the employment decision.
Please check box to confirm that you read the above statement
I hereby release employers, schools and persons from all liability in responding to inquiries in connection with my application. A criminal conviction will not automatically disqualify my application.
Please check box to confirm that you read the above statement
I also understand that I am required to abide by all rules and regulations of the agency and that I will be required to provide proof of citizenship or work permit at time of employment
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I understand that any offer of employment is conditional pending the results of my Staff Exclusion List Check, Criminal Background Check, Abuse/Neglect History check through OPWDD, Child Abuse Registry Check and Driving Abstract, PPD
Please check box to confirm that you read the above statement
First Name *
Middle
Last Name *
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