Human Resources Part Time

Application for Employment Form

** ****** ******, ********, *** York 11201

We consider all applicants for employment without regard to race, alienage or citizenship, color, religion, sex, gender

(including gender identity and sexual harassment), national origin, age, marital status, partnership status, sexual orientation, handicap or disability, military status, or status as a victim of domestic violence, stalking and sex offenses in accordance with federal, state, and local laws. In addition, we comply with applicable federal, state, and local laws prohibiting discrimination in employment based on arrest or conviction record. The corporation also provides "reasonable accommodations" to qualified individuals with disabilities, in accordance with the Americans with Disabilities Act and applicable state and local laws. This corporation is an Equal Opportunity Employer. Position Applied for: Date: Full Name (Last, First, Middle) Social Security No. (Optional) Current Address Street City State Zip Code

Apartment No. Telephone No. Referred by

If you are under 18 years of age, can you provide required proof of your eligibility to work? Yes [ ] No [ ] Do you want to work? Full Time [ ] Part Time [ ] If part time, specify days and hours: Are you willing to work overtime as necessary? Yes [ ] No [ ]

Date you can start: Salary desired: Have you ever been employed by us? Yes [ ] No [ ] If yes, when? Federal laws require that employers hire only individuals who are authorized to be lawfully employed in the United States. In compliance with such laws, all offers of employment are subject to verification of the applicant's identity and employment authorization, and it will be necessary for you to submit such documents as are required by law to verify your identification and employment authorization within three days of employment. Are you legally eligible for work in this country? Yes [ ]No [ ] State name(s) of any relative(s) in our employment and your relationship to them: RECORD OF EDUCATION

Do not write, “see resume.” This section must be filled out completely or this application cannot be processed. School Name and Address of

School

Course of

Study

Years

Completed

Did you

Graduate?

Diploma/ Degree

Date Received

High School

College

Graduate School

Other (Specify)

WORK HISTORY

List in order, last or current employer first. Account for all periods of unemployment. Do not write, “see resume.” This section must be filled out completely or this application cannot be processed. Employer Job Title Dates Employed

From To

Full Address Telephone Number(s)

Work Performed Supervisor Name & Title

Reason for Leaving Ending Salary

SKILLS/ LICENSES/ CERTIFICATIONS

Are there any other experiences, skills, or abilities that you feel especially qualify you for work with our company? Word Processing: words per minute

List all valid professional licenses and certifications (include Driver’s license, if relevant to the position). MILITARY SERVICE RECORD

Employer Job Title Dates Employed

From To

Full Address Telephone Number(s)

Work Performed Supervisor Name & Title

Reason for Leaving Ending Salary

Employer Job Title Dates Employed

From To

Full Address Telephone Number(s)

Work Performed Supervisor Name & Title

Reason for Leaving Ending Salary

Have you ever served in the U.S. Armed Forces? Yes [ ] No [ ] List duties in the Service, including special training that is relevant to the position for which you have applied. PERSONAL REFERENCES (excluding relatives or previous employers) Name and Occupation Dates Known Address Telephone Number The following information may be needed if it is related to the specific job for which you have applied. If you are unsure of the exact activities of the position, you should request a job description from Human Resources. Have you ever been debarred, excluded or otherwise deemed ineligible for participation in Federal health care programs

(Medicaid or Medicare) or in any other state or private health care program or managed care program, or is such a proceeding against you pending now? Yes [ ] No [ ] Have you ever been sanctioned, disciplined, or reprimanded by and local, state, or federal regulatory agency, such as, but not limited to, the New York State Department of Health, or is such a proceeding against you pending now? Yes [ ] No [ ]

Is there anything that would prevent you from performing in a reasonable and safe manner the activities involved in the position for which you have applied? Yes [ ] No [ ] The answers to the following questions will be reviewed and evaluated as required by law. Factors such as date of offense, seriousness and nature of the violation, rehabilitation and position applied for will be taken into account. This information will be treated as confidential.

Have you been convicted of a crime within the last 7 years? Yes [ ] No [ ] If yes, respond below. Is a criminal charge pending against you currently? Yes [ ] No [ ] If yes, respond below. State the nature of offense, when, where, and disposition. How did you learn about us?

Advertisement Friend Walk-In Employment Agency Relative Other

PRE-EMPLOYMENT STATEMENT

(Please read each statement carefully before signing) I understand and agree that:

1. The information that I have provided on this application is true and complete to the best of my knowledge. Any misrepresentation or omission of any fact in my application, résumé, or any other materials, or during any interviews, can be justification for refusal of employment, or, if employed, termination from the corporation’s employ. (Please initial) 2. Any offer of employment I may receive from the corporation is contingent upon my successful completion of the corporation’s pre-employment screening process, including the corporation’s receiving references that it considers satisfactory, and my satisfactory completion of any post-offer pre- employment medical examination that may be required. I also agree, if employed, to submit to a medical examination at any time at the corporation’s request. I hereby authorize and consent to having the results of any post offer pre-employment or post-employment medical examinations I may be required to take disclosed to the corporation. This consent shall last for as long as I am employed by the corporation. (Please initial)

3. I understand that as a condition of employment, I may be required to undergo and successfully pass a screening for alcohol and/or drugs. I also understand and agree that, if employed, I may be required to submit to an alcohol or drug screening at any time at the discretion of the corporation. I hereby authorize and consent to having the results of any such alcohol or drug screening I may be required to undergo disclosed to the corporation. This consent shall last for as long as I am employed by the corporation.

(Please initial)

4. In processing my application for employment, the corporation may verify all information provided by me, or may procure or have prepared a consumer or an investigative consumer report for this purpose concerning my prior employment, military record, education, character, general reputation, personal characteristics, criminal record, and mode of living. I understand that upon written request to the corporation, I will be informed whether an investigative consumer report was requested and given full information as to the nature and scope of this investigation. (Please initial) 5. I authorize and request that all of my present and former employers and those individuals I have listed as personal references furnish information about my employment record, including a statement of the reason for the termination of my employment, work performance, abilities and other qualities pertinent to my qualifications for employment. This authorization hereby releases them from any and all liability for damages arising from furnishing the requested information or expressing their opinions.

(Please initial)

6. In consideration of my employment, I agree to comply with the policies, rules, regulations, and procedures of corporation and understand that my employment and compensation can be terminated with or without cause or notice, at any time, at the option of either the corporation or myself.

(Please initial)

Signature Date HR-2010

START

TREATMENT AND RECOVERY CENTERS

OFFICE OF HUMAN RESOURCES MANAGEMENT

22 CHAPEL STREET

BROOKLYN, NEW YORK 11201

Reference Check Authorization

I authorize and request that all of my present and former employers and those individuals I have listed as personal references furnish information about my employment record, including a statement of the reason for the termination of my employment, work performance, abilities and other qualities pertinent to my qualifications for employment. This authorization hereby releases them from any and all liability for damages arising from furnishing the requested information or expressing their opinions.

(Print Name)

(Signature)

Authorization for Education Verification

I authorize and request that all of the academic institutions I have listed furnish my education record for the purpose of employment. This authorization hereby releases them from any and all liability for damages arising from furnishing the requested information.

(Print Name)

(Signature)

HR-2004

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