Name: Last First Middle Social Security Number

Pathways, Inc.

175 Milbank Avenue Greenwich, CT 06830

tel: 203.869.5656

fax: 203.869.4059

www.pathways-greenwich.org

Application for Employment

Name: Last First Middle Social Security Number

Address: Street City State Zip

Phone number: Cell Home

Email address:

Person to contact in case of emergency:___________________________Phone Number____________

Position Desired______________________________________Salary Expected___________________

Have you ever been employed by Pathways, Inc._________________If so, when?__________________

What position?____________________________

Have you previously applied to Pathways, Inc for employment?____________If so, when?____________

How did you learn of our organization?_____________________________________________________

Have you ever been convicted of a crime (excluding minor traffic violations)?_______________________

If yes, give dates, types of offenses and result of charges:______________________________________ _______________________________________________________________________________________________________________________________________________________________________

Have you ever been found guilty of professional malpractice? Yes______________ No_______________

If yes, give dates, types of offenses and result of charges:______________________________________

________________________________________________________________________________________________________________________________________________________________________

Have your license or professional registration, clinical privileges, staff privileges, professional society membership, or any other institutional affiliation ever been denied, revoked, suspended, reduced, placed on probation, or otherwise relinquished? Yes___________No___________

If yes, Please explain:__________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________

Education

School Name &Location Degree or Diploma

High School____________________________________________________________

College________________________________________________________________

Graduate______________________________________________________________

Post Graduate__________________________________________________________

Other_________________________________________________________________

Certifications, Licenses, Honors, etc. (List only those that relate to this position for which you are applying and omit any that disclose your race, creed, sex, religion, etc.)

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Membership in Professional or Civic Organizations (Exclude those which may disclose your race, color, religion or national origin). ___________________________

Personal References

List three references that are of a professional nature, not relatives or friends.

Name Occupation Company Name & Address Telephone

1. ____________________________________________________________________

2.__________________________________________________________________________________

3.__________________________________________________________________________________

Please complete information in this section that is not included in your resume. Begin with your current or most recent position.

Name of last or Current Employer: Address City State Zip

____________________________________________________________________________

Telephone Number: Position Title: Supervisor’s Name

____________________________________________________________________________

Date Employment began: Date employment ended: Starting salary: Ending salary:

____________________________________________________________________________

Reason for leaving: MAY WE CONTACT THIS EMPLOYER?

____________________________________________________________________________

Responsibilities of this position: ___________________________________________________

____________________________________________________________________________

Name of Previous Employer: Address City State Zip

____________________________________________________________________________

Telephone Number: Position Title: Supervisor’s Name

____________________________________________________________________________

Date Employment began: Date employment ended: Starting salary: Ending salary:

____________________________________________________________________________

Reason for leaving: MAY WE CONTACT THIS EMPLOYER?

____________________________________________________________________________

Responsibilities of this position: ___________________________________________________

____________________________________________________________________________

Name of Previous Employer: Address City State Zip

____________________________________________________________________________

Telephone Number: Position Title: Supervisor’s Name

____________________________________________________________________________

Date Employment began: Date employment ended: Starting salary: Ending salary:

____________________________________________________________________________

Reason for leaving: MAY WE CONTACT THIS EMPLOYER?

____________________________________________________________________________

Responsibilities of this position: ___________________________________________________

READ BEFORE SIGNING

The distribution or receiving of this application by Pathways, Inc. does not imply an agreement of contract to employ the applicant.

The purpose of this application is solely to allow persons a standardized form on which to submit their qualifications.

Pathways, Inc. is authorized to investigate any information contained herein or information relating to my business background.

My statements and answers to the foregoing are true and complete to the best of my knowledge. I understand that false or misleading statements may result in being disqualified or terminated.

The Immigration Reform and control Act requires employers to view original documents confirming the identity and right to work of all applicants about to be hired.

Pathways, Inc. is an Equal Opportunity employer and considers all candidates for employment regardless of race, creed, color, religion, sex, national origin, age, handicap or disability, marital status or veteran’s status.

I hereby acknowledge that I have read this application form and understand the purpose and the content of the information requested.

_______________________________________ _____________________

Applicant’s Signature Date

DF: 12/12