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Check this box if you are applying for more than 1 position
     
 
Enter your first name :
  Last Name :
Your Email address :
 
Address 1:
 
Address 2:
 
City :
 
State :
 
Zip Code :
 
Home Phone :
 
Work Phone :
 
Position Applied For :
 
Check the highest grade you completed :
 
 
Name and location of last primary or
secondary school attended :
 
 
              Did you complete High School? :
  Yes No
 
If you answered no to the question above,
do you have a high school equivalency diploma? :
Yes No NA
     
  College  
 
Name of College :
 
Location of College :
 
Hours :
 
Degree :
     
 
Name of College :
 
Location of College :
 
Hours :
 
Degree :
     
 
Name of College :
 
Location of College :
 
Hours :
 
Degree :
     
 
If you expect to complete your
educational program in the near
future, please indicate what
type of degree and when
you expect to receive it.:
     
  Work Experience  
   
EXPERIENCE Please note: Although you are welcomed to attach resume, it is required you fully complete sections 8-11 of this form. Please describe all paid, military and applicable voluntary experience starting with the most recent. You may list significantly different jobs with the same organization as separate items.
     
Job 1
Job Title :
 
Employer :
 
Employer Address :
 
Employer Phone :
 
Type of Business :
 
Immediate Supervisor :
 
Number and Types of employees you supervised :
 
Job Duties :
(MAX 380 characters)
Employment dates from :
To example: 02-05-2008-2009
 
Reason for leaving :
 
Name if different from present :
     
Job 2
Job Title :
 
Employer :
 
Employer Address :
 
Employer Phone :
 
Type of Business :
 
Immediate Supervisor :
 
Number and Types of employees you supervised :
 
Job Duties :
(MAX 380 characters)
Employment dates from :
To example: 02-05-2008-2009
 
Reason for leaving :
 
Name if different from present :
     
Job 3
Job Title :
 
Employer :
 
Employer Address :
 
Employer Phone :
 
Type of Business :
 
Immediate Supervisor :
 
Number and Types of employees you supervised :
 
Job Duties :
(MAX 380 characters)
Employment dates from :
To example: 02-05-2008-2009
 
Reason for leaving :
 
Name if different from present :
     
Job 4
Job Title :
 
Employer :
 
Employer Address :
 
Employer Phone :
 
Type of Business :
 
Immediate Supervisor :
 
Number and Types of employees you supervised :
 
Job Duties :
(MAX 380 characters)
Employment dates from :
To example: 02-05-2008-2009
 
Reason for leaving :
 
Name if different from present :
     
  CLERICAL SKILLS  
     
 
Typing Speed :
 
Shorthand Speed :
 
List Computer Applications :
     
  ADDITIONAL INFORMATION  
     
   
Use this space for any additional information you think would help Region Ten evaluate your application, including training, volunteer or personal experience applicable to this application, including seminars, workshops or special achievements
(MAX 600 characters)
   
     
  CREDENTIALS  
     
 
License Number :
Type
 
Granted by :
Expires
     
 
License Number :
Type
 
Granted by :
Expires
     
 
License Number :
Type
 
Granted by :
Expires
     
  REFERENCES  
Current and former employers/supervisors will be contacted (in the case of final candidate only). Please use this space to indicate others that we may contact who you feel have knowledge of your character and skills.
     
 
Reference Name :
Phone Number
 
Reference Name :
Phone Number
 
Reference Name :
Phone Number
     
 
How did you find out about this employment opportunity :
   
* If "Other", please specify.
   
     
     
  AVAILABILITY/ELIGIBILITY  
     
   
Which Schedule Are You Willing To Work? :
 
(Select all that apply.) :
  
Day
Evening
Weekend Day
Overnight
Weekend Evening
Full Time
Part Time
When will you be available to start work :
example: 02-05-2008-2009
 
Are you willing to provide your own transportation if necessary for employment? :
   Yes No
 
Have you been convicted of a motor vehicle violation? :
   Yes No *
 
Are you legally eligible for employment in the United States? :
   Yes No
 
Have you been convicted of a criminal violation excluding juvenile offenses? :
   Yes No *
 
Do you have any current felony charges against you? :
   Yes No *
   
* If "Yes", please explain.
   
   
I hereby certify that all articles and attachments are true. I understand that all information on this application is subject to verification and I consent to former employers being contacted regarding this application. I further consent to background checks through the Division of Motor Vehicles, the Federal Bureau of Investigations, or other law enforcement registries. I understand that I will be asked to sign a release permission form witnessed by a notary allowing a criminal background check through the New York State Police Department or other police agencies.
 
 
   Yes No   Today's Date:   
     
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