The CharltonSchool

Application for Employment

Interview: _____/_____/______M
2nd Interview: _____/_____/______M

Hired:_____/_____/_____ Start:_____/_____/_____

Date: _____/_____/_____

Name: ______Soc. Sec.#______

Address: ______Home Tele.(____)______

______Work Tele.(____)______

CityStateZip Cell: (____)______

Can we call you at work? ______

Do you possess a valid NYS Driver’s License?[ ]Yes[ ]No

Have you ever been employed by us? ______If yes, when? ______

Position applied for: ______

Available [ ] Full-Time[ ] Part-TimeIf Part-Time, What hours/days______

Can you work?S M T W T F S ______

Can you work overtime if asked? ______When can you start? ______

Are you legally eligible for employment in the United States? ______

Special skills/training that may be useful in working for The Charlton School?______

EDUCATION

School / Name, Address of School attended / Course of Study / No. Years completed / Did you Graduate / Degree/
Diploma
Elementary
High School
College
Other

Personal References (3) Other than relatives or previous employers:

Name (please print)Address, City, State, ZipPhone Number

______( ) ______

______( ) ______

______( ) ______

yk c:\My doc\Forms\Application-Emp

Employment – (Most recent first)

Company ______Tele. (____) ______

Address ______Employed:____/____/____ to ____/____/____

______Rate of pay: ______

CityStateZip

Describe Duties:______

Reason for Leaving:______Supervisor:______

Company ______Tele. (____) ______

Address ______Employed:____/____/____ to ____/____/____

______Rate of pay: ______

CityStateZip

Describe Duties:______

Reason for Leaving:______Supervisor:______

Company ______Tele. (____) ______

Address ______Employed:____/____/____ to ____/____/____

______Rate of pay: ______

CityStateZip

Describe Duties:______

Reason for Leaving:______Supervisor:______

Company ______Tele. (____) ______

Address ______Employed:____/____/____ to ____/____/____

______Rate of pay: ______

CityStateZip

Describe Duties:______

Reason for Leaving:______Supervisor:______

Employers above will be contacted unless you indicate those you do not want us to contact, and why.

Do not contact ______Reason ______

MILITARY

Branch of Service:______Active Duty: ____/____/____ to ____/____/____

Rank at Discharge: ______Date of Discharge: ____/____/____

Duties/Special Training: ______

Do you have any physical conditions that may limit you in any way in your ability to perform the duties of the job for which you are applying? _____

If yes, explain: ______

______

Have you ever been convicted of a crime in New YorkState or any other jurisdiction? [ ] Yes [ ] No If yes, Explain:

______

I UNDERSTAND AND AGREE THAT:

  1. Any material misrepresentation or deliberate omission of a fact in my application or interview, may be justification for refusal of, or if employed, termination from employment.
  1. The CharltonSchool may make a thorough investigation of my work history and may verify all data given in my application for employment, related papers or oral interviews. I authorize such a review and the receiving of any information requested by the agency and I release from liability any person giving or receiving any such information. I understand that falsification of data so given or other disqualifying information discovered as a result of this investigation may prevent my being hired, or if hired, may subject me to dismissal.
  1. If I have been convicted of a crime, The Charlton School may choose to obtain my criminal record.
  1. My employment may be terminated by The Charlton School at any time.
  1. I am required to take a physical examination annual to determine if I am physically fit for the job I am to perform, and, I authorize any physician or hospital to release any information which may be necessary to determine my ability to perform the duties of the job I am considered for prior to employment or in the future during my employment with the agency.
  1. After I am hired, The Charlton School may check with DMV in order to review my driving record.
  1. The CharltonSchool may make at times the following work conditions mandatory: overtime, shift work, a rotating work schedule, or a work variable schedule. I understand and accept these as conditions of my continuing employment.
  1. That employees of The Charlton School are required under Section 424-a of the Social Services Law to be screened with the State Central Register to determine if they are the subject of an indicated child abuse or maltreatment report.
  1. This is an Application for Employment and that no employment contract is being offered.
  1. If employed, such employment is for an indefinite period of time and the agency can change wages, benefits and conditions at any time.

I have read and understand the above. ______/___/___

THE CHARLTONSCHOOL

VOLUNTARY AFFIRMATIVE ACTION DATA

Please Note: Completion of this form is voluntary. We consider all applicants for positions without regard to race, color, religion, sex, national origin, citizenship, age, disabilities, veteran/reserve, or any other similarly protected status. We also comply with all applicable laws governing employment practices and do not discriminate on the basis of any criteria.

To be completed by applicant on a voluntary basis. Not for interview purposes: In an effort to comply with requirements regarding government recordkeeping, reporting, and other legal obligations which may apply, we request that you complete this applicant data survey. Providing this information is strictly voluntary. Failure to provide it will not subject you to any adverse personnel decisions. Your cooperation is appreciated.

APPLICANT INFORMATION:

Applicant Name:______Date:______

Address:______

Sex: Male_____ Female_____ Position Applied For:______

Referral Source:______

Please select one of the following Equal Employment Opportunity Identification Groups:

White (not of Hispanic origin) ______Asian or Pacific Islander ______

Black (not of Hispanic origin) ______American Indian/Alaskan Native ______

Hispanic ______

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ADMINISTRATIVE USE:

Position Applied For:______Current Opening:______

Hired: Yes _____ No _____ Date of Hire: ______

Position Hired For: ______

Additional Notes:______

______

Completed By:______Date:______

For Office Use Only

Results of Interview

Employ: Yes [ ] No [ ]Employment Date: ____/____/____

Full Time [ ]Part Time [ ]Starting Date:____/____/____

Job Title: ______Salary $______

Approved by:

______Date: ____/____/____

Name and Title

Interview

Date: ____/____/____Interviewer: ______

Comments: ______

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Interview

Date: ____/____/____Interviewer: ______

Comments: ______

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Results of Telephone References

(For Office use Only)

Applicant: ______

Date: ____/____/____Company: ______

Contact Name: ______

Comments: ______

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Date: ____/____/____Company: ______

Contact Name: ______

Comments: ______

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Date: ____/____/____Company: ______

Contact Name: ______

Comments: ______

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