State Of New York
Governor’s Office Of Employee Relations/Labor-Management Committees
EMPLOYMENT APPLICATION
Name:_________________________________________________________________
Home Address:_______________________________________________________________________
Telephone Numbers: Business:___________________ Home:__________________________
Social Security Number:________________________________________________________________
Do you have the legal right to be employed in the United States? Yes_____ No_____
(Documentation will be required at the time of appointment)
Veteran Status: Veteran_____ Non-Veteran_____ Disabled_____
Dates of Service__________ Branch of Service__________
Are you over 18 years of age? Yes_____ No_____ If No, State Age____________
EDUCATION: Either attach a copy of your resume giving your educational history, or fill out this section.
Resume Attached
High school graduate or equivalency diploma? Yes_____ No_____
College Degree Major No. of Credits
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
EMPLOYMENT HISTORY: Either attach a copy of your resume or fill out this section.
Resume Attached
Dates Name of Business Reason For
Employed or Agency Title Supervisor Leaving
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
YOU MUST ANSWER THE QUESTIONS AND SIGN YOUR NAME ON THE BACK OF THIS FORM.
Except for minor traffic violations, have you ever been convicted of a crime?
Yes_____ No_____ If yes, give circumstances of each conviction:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Please name at least two work references we may contact (name, address & telephone number):
__________________________________________________________________________________
__________________________________________________________________________________
Use this space for any additional information that you wish to include:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
I hereby affirm that all of the statements made on this form are true and accurate to the best of my knowledge and authorize you to make inquiries of my previous employment.
______________________________________ _______________________________
Signature Date
In case of emergency, notify:
______________________________________ _______________________________
Name Telephone Number
______________________________________
Address
In compliance with federal and state equal employment opportunity laws, discrimination in employment because of age, race, religion, creed, color, national origin, sex, disability, marital status, criminal record or sexual orientation is prohibited.
TO BE COMPLETED BY AGENCY
Position being applied for:______________________________________________________________
GOER Unit or LMC:___________________________________________________________________
ADM-254 9/02