THE REHABILITATION CENTER 1439 BUFFALO STREET OLEAN, NEW YORK 14760 APPLICATION FOR EMPLOYMENT APPLICANTS ARE CONSIDERED FOR ALL POSITIONS WITHOUT REGARD TO RACE, COLOR, RELIGION, SEX, NATIONAL ORIGIN, SEXUAL ORIENTATION, AGE, MARITAL OR VETERAN STATUS OR THE PRESENCE OF A NON-JOB-RELATED MEDICAL CONDITION OR HANDICAP. REASONABLE ACCOMMODATIONS WILL BE MADE DURING THE APPLICATION PROCESS, IF NECESSARY. THE REHABILITATION CENTER SUPPORTS A DRUG-FREE WORKPLACE. ALL NEW EMPLOYEES WILL BE REQUIRED TO PASS A DRUG TEST AS A CONDITION OF EMPLOYMENT. THIS DRUG TESTING MUST BE COMPLETED WITHIN 48 HRS OF NOTIFICATION.
Date:
Position Applied For:	Salary Expected:
First Name:	Middle Name:
Last Name:	Email Address:
Address:
Street:	City:
State:	Zip Code:
Social Security Number: - -
Primary Phone Number: - -	Alternate Phone Number: - -
Referal Source: - Please check all that apply.
Advertisment: Empoyment Agency: School: Relative: Other:
Are you under 18 years of age?	Yes No
Have you ever been employed here before?	Yes No
If YES, give data:
On what date would you be available for work?
Do you have relatives employed with the Agency?
If Yes, give name and relationship.
Are you employed now?	Yes No
May we contact your present employer?	Yes No
Are you a United States Citizen?	Yes No
Are you available to work:
Full Time: Part Time: Shift Work: Temporary: On Call: Nights: Weekends: Holidays:
Will you work irregular hours?	Yes No
Have you ever been convicted of a crime?	Yes No
Do you have any criminal charges pending?	Yes No
Have you ever been investigated by the Office of Professional Discipline?	Yes No
Have you ever been investigated or convicted of Medicaid Fraud?	Yes No
If you have a professional license, has your license ever been suspended or revoked?	Yes No
If you answered yes to any of the last five questions, please explain.
EMPLOYMENT EXPERIENCE Start with your present or last job. Include military service assignments, volunteer activities and child care. (IN THE MARGIN, PLEASE INDICATE ANY OTHER NAMES YOU WERE KNOWN BY AT EACH PLACE OF EMPLOYMENT)
Organization(Name):
Street Address:
City:	State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming     Zip Code:
Phone Number: - -	Dates Employed: From:  To:
Job Title:	Supervisor:
Work Performed:
Rate of Pay: Beginning:    Final:
Organization(Name):
Street Address:
City:	State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming     Zip Code:
Phone Number: - -	Dates Employed: From:  To:
Job Title:	Supervisor:
Work Performed:
Rate of Pay: Beginning:    Final:
Organization(Name):
Street Address:
City:	State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming     Zip Code:
Phone Number: - -	Dates Employed: From:  To:
Job Title:	Supervisor:
Work Performed:
Rate of Pay: Beginning:    Final:
Organization(Name):
Street Address:
City:	State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming     Zip Code:
Phone Number: - -	Dates Employed: From:  To:
Job Title:	Supervisor:
Work Performed:
Rate of Pay: Beginning:    Final:
Do you have any other experience with care of or service to developmentally disabled individuals, including relevant certification, licenses, training, etc.? Please list here.
Did you graduate from high school?	Yes No
If not, have you obtained a GED?	Yes No
Education:
High School:	City / State:
Major / Degree:	Years Attended:
College:	City / State:
Major / Degree:	Years Attended:
College:	City / State:
Major / Degree:	Years Attended:
College:	City / State:
Major / Degree:	Years Attended:
Trade School:	City / State:
Major / Degree:	Years Attended:
Give name, address and telephone number of 3(three) personal references who are NOT RELATED to you who can attest to your character, reputation, and personal qualifications: DO NOT DUPLICATE supervisors listed under employment
Name of First Reference:	Phone Number: - -
Full Address:
Name of Second Reference:	Phone Number: - -
Full Address:
Name of Third Reference:	Phone Number: - -
Full Address:
OFFICE / CLERICAL Applicants Only:
Keyboarding Speed:	WPM
Dictation:	WPM
10 Key Calculator Speed:
I have experience with the following business machines:
I have experience with the following software/computer programs:
CONDITIONS FOR EMPLOYMENT for The ReHabilitation Center Please read the following statements carefully as they constitute conditions for employment:
1. The information that I have provided on this application is accurate and true to the best of my knowledge. 2. I affirm that I have read this completed application and I have not withheld any information or response to any questions and that the information I have furnished is true and correct. I understand that any misrepresentation or omission of a fact on my application or during the interview or hiring process regardless of when such misrepresentation or omission is discovered, may result in the refusal of employment, or if employed, immediate termination. 3. The persons, schools, current and prior employers, educational institutions in this application (if approved by me in the Employment Record section), or law enforcement agencies are authorized by me to verify the information I have provided and to provide the Rehabilitation Center with information that may be requested by it to arrive at an employment decision. I am willing that a photocopy of this authorization be accepted with the same authority s the original. I hereby waive and release all persons, schools, current and prior employers and other organizations from, any liability arising from the disclosure of any of the above information whether in writing or orally, and further waive, and release the Rehabilitation Center from any liability arising from reliance on the aforementioned information or the use, publication, or retention of such information within the context of its applicant review procedures. 4. I agree to protect the Rehabilitation Center's confidential information, trade secrets, and names or addresses of clients, and I will not disclose to the ReHabilitation Center, any confidential information of others. 5. I will be able, if hired, to certify that I am authorized to work in the United States of America, and understand that in accordance with the Immigration Reform and Control Act that I will be required to provide timely documentation of identity and employment eligibility. 6. In the event I receive a conditional offer of employment, I understand that I will be subject to a drug and alcohol screen as well as a Criminal Background check. I consent to the release of all information and test results directly to the ReHabilitation Center. I understand that employees hired by the ReHabilitation Center are required to provide evidence of being free of active TB. The customary form of verification is a PPD screening. I also understand that if I am actively being considered for employment in a position requiring regular and substantial contact with children, the ReHabilitation Center is required by law to inquire with the State Central Register regarding an indicated report of child abuse or maltreatment on file with the Department of Social Services. 7. In the event that I am employed, I agree to conform to the ReHabilitation Center's rules and regulations, I understand and agree that if I am employed, I shall be employed on an at-will basis. As an at-will employee, I understand and agree that either the ReHabilitation Center or I can terminate our employment relationship at any time for any reason with or without advance notice and with or without cause. I understand and agree that, although over the course of my employment, other terms and conditions of my employment may change, the at-will term of my employment will not change. I understand that no representative of the ReHabilitation Center has any authority to make an agreement contrary to the foregoing or to enter into any agreement for employment for any specific period of time. 8. For applicants who will have regular and substantial unsupervised or unrestricted contact with people receiving services, the applicant shall provide information, statements, and fingerprints as maybe necessary for a criminal history record check to be conducted according to the requirements of 14 NYCRR Section 633.22. New York State Office of Mental Retardation and Developmental Disabilities will make a permanent hiring decision based on the information from the criminal history record check. If this criminal history record check is necessary, you will be considered a temporary employee until your hire is authorized by OMRDD. Your signature below give permission for this criminal history record check.
STATEMENT OF MOVING VIOLATIONS
Do you have a valid Driver's License?	Yes No
Please check one of the two boxes below and complete other information as indicated.
No	I do not wish to be considered for any position requiring driving of an Agency vehicle, even on an occasional basis.
Yes	I would like to be considered for a position that may require some driving of an Agency vehicle. If checked, complete the following: [NOTE: Passenger cars or Agency vans only, no buses.]
My record of moving violations in the last three years and any suspension, revocation, DWI convictions, or any occurrence involving harm to anyone or property include:
Type of Violation:	Date:
Type of Violation:	Date:
Type of Violation:	Date:
Type of Violation:	Date:
Type of Violation:	Date:
THIS INFORMATION WILL BE VERIFIED IF YOU ARE HIRED AND MISREPRESENTATION OF THIS INFORMATION WOULD BE GROUNDS FOR DISMISSAL.
INTERVIEW EXERCISE
Please write a narrative explaining why you are qualified to successfully fill this position and some of your goals/achievements.
____________________	____________________
Name	Date
Please print and sign application summary. Bring this document with you so you do not need to fill out an application at your interview.