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

Last Name(required)

First Name(required)

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

Email Address(required)

Phone Number(required)

Position(required)

Date You Can Start(required)

Current Employer Name

Current Employer Phone Number

Schedule (Hours) – Monday(required)

Schedule (Hours) – Tuesday(required)

Schedule (Hours) – Wednesday(required)

Schedule (Hours) – Thursday(required)

Schedule (Hours) – Friday(required)

Education – High School Name(required)

Education – High School Major

Education – College Name

Education – College Major

Special Training, Skills, Etc.(required)

Prior Experiences with Groups of Children(required)

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(required)

References (No Relatives) – Reference #1 Address(required)

References (No Relatives) – Reference #1 Phone Number(required)

References (No Relatives) – Reference #2 Name(required)

References (No Relatives) – Reference #2 Address(required)

References (No Relatives) – Reference #2 Phone Number(required)

References (No Relatives) – Reference #3 Name(required)

References (No Relatives) – Reference #3 Address(required)

References (No Relatives) – Reference #3 Phone Number(required)

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.