40 Jon Barrett Road

40 Jon Barrett Road

Patterson, New York 12563

EMPLOYMENT APPLICATION

Instructions: All sections of this application are to be completed in full. Attaching a resume alone does not constitute a completed application.

HUDSON VALLEY CEREBRAL PALSY ASSOCIATION

IS AN EQUAL OPPORTUNITY EMPLOYER

We do not discriminate because of race, sex, color, religion, age, marital status, national origin or disability.

Name

Last First Middle Initial

Present Address

City State Zip

Home Telephone No. ( )

Alternate Telephone No. ( )

Position(s) applied for Rate of pay expected $ ______

Which days are you available to work?

Monday / Tuesday / Wednesday / Thursday / Friday / Saturday / Sunday
Preferred Shift: 1st ____ 2nd _____ 3rd ____ / Full-Time Part-Time Per Diem (on call)
Samples hrs: 8 am – 4 pm ; 4 pm – 12 pm ; 12 pm – 8 am

https://spoint.hvcpa.org/hr/Shared Documents/Form/Employment Application - May 2014.doc

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Have you worked for Hudson Valley Cerebral Palsy Association or any other affiliate of Cerebral Palsy of New York State? Yes No. If yes when?

How were you referred to Cerebral Palsy?

Are you over 18 years of Age? Yes No

Are you eligible to work in the United States of America? Yes No

Have you ever been convicted of a crime, in New York State or elsewhere? Yes No

If Yes describe in full. ______

Do you have any pending charges against you, in New York State or elsewhere? Yes No

If Yes describe in full. ______

Do you have any relatives that work at Hudson Valley Cerebral Palsy Association? Yes No

If Yes, Please indicate Name: Department

Educational Background

Education / Name & Address of School / Years Attended (Specify) /

Did You Graduate

/ Major or Degree
High School / Yes No

College

/ Yes No
Graduate / Yes No
Trade School / Yes No

Do you type? If Yes WPM

New York State Driver’s License # Expiration Date:

How many years have you had your New York State Driver’s License? ______

Other State Driver’s License # ______State: ____ Expiration Date:

Professional Certification / License & Memberships ______

All applicants are requested to provide a copy of their drivers’ license if they are a licensed driver. Out of state applicants must obtain a copy of their driving record before employment can begin if driving is a primary function of their position.

1 / Company Name: / Telephone
Address: / Employed – Month & Year
From: To:
Name of Supervisor: / Weekly Pay
Start: Last:
Job Title – Starting Position:
Job Title - Current Position:
Describe your work: / Reason for Leaving:
May we contact your present employer now? Yes No. If no, when?
2 / Company Name: / Telephone
Address: / Employed – Month & Year
From: To:
Name of Supervisor: / Weekly Pay
Start: Last:
Job Title – Starting Position:
Job Title - Ending Position:
Describe your work: / Reason for Leaving:
3 / Company Name: / Telephone
Address: / Employed – Month & Year
From: To:
Name of Supervisor: / Weekly Pay
Start: Last:
Job Title – Starting Position:
Job Title - Ending Position:
Describe your work: / Reason for Leaving:

4 / Company Name: / Telephone
Address: / Employed – Month & Year
From: To:
Name of Supervisor: / Weekly Pay
Start: Last:
Job Title – Starting Position:
Job Title - Ending Position:
Describe your work: / Reason for Leaving:
5 / Company Name: / Telephone
Address: / Employed – Month & Year
From: To:
Name of Supervisor: / Weekly Pay
Start: Last:
Job Title – Starting Position:
Job Title - Ending Position:
Describe your work: / Reason for Leaving:
6 / Company Name: / Telephone
Address: / Employed – Month & Year
From: To:
Name of Supervisor: / Weekly Pay
Start: Last:
Job Title – Starting Position:
Job Title - Ending Position:
Describe your work: / Reason for Leaving:

Please respond to the following questions:

1.  Have you had any moving or traffic violations? Yes No

If yes, please list. ______

2. Was your license ever suspended? Yes No. Was your license ever revoked? Yes No

If yes, please explain. ______

3.  Please list all suspensions, revocations, DWIs, convictions or any occurrence involving harm to persons or property while driving?

Please list and include dates.

______

4.  Have you had a driver’s license for more than three years, excluding any probation or revocation periods? Yes No

APPLICANTS STATEMENT - PLEASE READ CAREFULLY

I authorize this agency to contact previous employers. I agree to take a physical for the position applied for. I certify that answers given herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. In the event of employment, I understand that false or misleading information given in my application or interview(s) shall be sufficient cause for immediate dismissal. I understand also, that I am required to abide by all rules and regulations of Hudson Valley Cerebral Palsy Association.

All information and answers provided on application are true.

Applicant’s Signature: Date:

https://spoint.hvcpa.org/hr/Shared Documents/Form/Employment Application - May 2014.doc

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Hudson Valley Cerebral Palsy Association

40 Jon Barrett Road

Patterson, NY 12563

845- 878-9078 Ext. 5951

Fax # 845-278-6979

CONFIDENTIAL EMPLOYMENT REFERENCE

(HR Department to fill in – please sign below by Applicant’s Signature)

TO:

Dear

has applied for a position as at our agency and has given your name as a reference. Please provide the information requested below and return to the above fax number.

POSITION HELD:

DATES OF EMPLOYMENT:

REASON FOR SEPARATION:

WOULD YOU RE-HIRE? Yes NO

ADDITIONAL COMMENTS:

Signature Title Date

******************************************************************************

APPLICANT APPROVAL: I hereby authorize this agency to receive information from individuals and organization, which I have identified.

Applicant’s Signature: Date:
Hudson Valley Cerebral Palsy Association

40 Jon Barrett Road

Patterson, NY 12563

845- 878-9078 Ext. 5951

Fax # 845-278-6979

CONFIDENTIAL EMPLOYMENT REFERENCE

(HR Department to fill in – please sign below by Applicant’s Signature)

TO:

Dear

has applied for a position as at our agency and has given your name as a reference. Please provide the information requested below and return to the above fax number.

POSITION HELD:

DATES OF EMPLOYMENT:

REASON FOR SEPARATION:

WOULD YOU RE-HIRE? Yes NO

ADDITIONAL COMMENTS:

Signature Title Date

******************************************************************************

APPLICANT APPROVAL: I hereby authorize this agency to receive information from individuals and organization, which I have identified.

Applicant’s Signature: Date:
Hudson Valley Cerebral Palsy Association

40 Jon Barrett Road

Patterson, NY 12563

845- 878-9078 Ext. 5951

Fax # 845-278-6979

CONFIDENTIAL EMPLOYMENT REFERENCE

(HR Department to fill in – please sign below by Applicant’s Signature)

TO:

Dear

has applied for a position as at our agency and has given your name as a reference. Please provide the information requested below and return to the above fax number.

POSITION HELD:

DATES OF EMPLOYMENT:

REASON FOR SEPARATION:

WOULD YOU RE-HIRE? Yes NO

ADDITIONAL COMMENTS:

Signature Title Date

******************************************************************************

APPLICANT APPROVAL: I hereby authorize this agency to receive information from individuals and organization, which I have identified.

Applicant’s Signature: Date:

Hudson Valley Cerebral Palsy Association

40 Jon Barrett Road

Patterson, NY 12563

845- 878-9078 Ext. 5951

Fax # 845-278-6979

PERSONAL REFERENCE LIST

OPWDD statutes require all applicants to provide the agency with 3 Personal References excluding previous employers and relatives. All information obtained through this reference check will remain confidential.

NAME:
ADDRESS:
DAY-TIME TELEPHONE:
E MAIL:
RELATIONSHIP:
NAME:
ADDRESS:
DAY-TIME TELEPHONE:
E MAIL:
RELATIONSHIP:
NAME:
ADDRESS:
DAY-TIME TELEPHONE:
E MAIL:
RELATIONSHIP:

______

Signature Date

Hudson Valley Cerebral Palsy Association

40 Jon Barrett Road

Patterson, NY 12563

845- 878-9078 Ext. 5951

Fax # 845-278-6979

INFORMED CONSENT AND AUTHORIZATION

To Whom It May Concern

I ______understand that it is necessary for Hudson Valley Cerebral Palsy Association to secure requested information concerning my past employment and education.

I therefore consent to and authorize the release to Hudson Valley Cerebral Palsy Association of any and all information concerning these matters.

Signature Date

https://spoint.hvcpa.org/hr/Shared Documents/Form/Employment Application - May 2014.doc

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