Employment Application

Fill out and submit the employment application below. You will be contacted after submission as time permits to discuss your employment application submission.

Click to open a printable Employment Application

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Last Name

First Name

Address (Ex: 59 Pomeroy Street, Apt. 3, Cortland, NY 13045)

Email Address

Phone Number

Position

Date You Can Start (YYYY-MM-DD)

Current Employer Name

Current Employer Phone Number

May We Contact Your Current Employer

Schedule (Hours) – Monday

Schedule (Hours) – Tuesday

Schedule (Hours) – Wednesday

Schedule (Hours) – Thursday

Schedule (Hours) – Friday

Education – High School Name

Education – High School Graduate

Education – High School Major

Education – College Name

Education – College Graduate

Education – College Major

Special Training, Skills, Etc.

Prior Experiences with Groups of Children

Employment History – Employer #1 Name

Employment History – Employer #1 Dates of Employment

Employment History – Employer #1 Address (Ex: 59 Pomeroy Street, Apt. 3, Cortland, NY 13045)

Employment History – Employer #1 Position

Employment History – Employer #1 Phone Number

Employment History – Employer #2 Name

Employment History – Employer #2 Dates of Employment

Employment History – Employer #2 Address (Ex: 59 Pomeroy Street, Apt. 3, Cortland, NY 13045)

Employment History – Employer #2 Position

Employment History – Employer #2 Phone Number

Employment History – Employer #3 Name

Employment History – Employer #3 Dates of Employment

Employment History – Employer #3 Address (Ex: 59 Pomeroy Street, Apt. 3, Cortland, NY 13045)

Employment History – Employer #3 Position

Employment History – Employer #3 Phone Number

References (No Relatives) – Reference #1 Name

References (No Relatives) – Reference #1 Address

References (No Relatives) – Reference #1 Phone Number

References (No Relatives) – Reference #2 Name

References (No Relatives) – Reference #2 Address

References (No Relatives) – Reference #2 Phone Number

References (No Relatives) – Reference #3 Name

References (No Relatives) – Reference #3 Address

References (No Relatives) – Reference #3 Phone Number

Have You Ever Been Convicted of a Felony or Misdemeanor?

If Yes, Please Explain

By clicking the submit button below, I authorize the investigation of all statement contained in this application. I understand that misrepresentation of facts stated above may be cause for dismissal. Further, I understand and agree that my employment is for no definite period and may be terminated at any time without previous notice or cause. I also understand that if hired, I am required to abide by all rules and regulations of this program and the licensing requirement of the New York State Department of Social Services.