EMPLOYMENT
APPLICATION
North Country Transitioinal Living Services, Inc.
482 Black River Parkway
Watertown, NY 13601
(315) 782-1777

Prospective Employees will receive consideration without discriminartion because of race, color, creed, national origin, gender, age, marital status, or disability status, or any other basis prohibited by federal, state or local law.

NAME
EMAIL
ADDRESS
CITY, STATE, ZIP PHONE
(All staff must be available by phone for emergencies and for necessary clarification of issues that occur on their shift.)
POSITION DESIRED FULL OR PART TIME
ARE YOU LEGALLY ELIGIBLE FOR EMPLOYMENT IN THE UNITED STATES?
DID ANYONE REFER YOU? IF SO, WHO?
ARE YOU AVAILABLE TO WORK OVERTIME? SOCIAL SECURITY #
DO YOU KNOW OR ARE YOU RELATED TO ANYONE WHO WORKS FOR THIS AGENCY?
EMERGENCY CONTACT PHONE

SCHOOL NAME & LOCATION OF SCHOOL COURSE OF STUDY NO. OF YEARS COMPLETED DID YOU GRADUATE? DEGREE OR DIPLOMA TYPE
GRADUATE
UNDER GRADUATE
BUSINESS TRADE TECHNICAL
HIGH
SCHOOL

EMPLOYMENT HISTORY
Include the last 7 years; list all previous employment; explain any periods of unemployment; list current or latest first.
#1
 EMPLOYER:
ADDRESS:
TELEPHONE:
SUPERVISOR:
DATES EMPLOYED:
TITLE OR POSITION:
DESCRIPTION OF JOB DUTIES:
REASON FOR LEAVING:
MAY WE CONTACT THIS EMPLOYER?:

 

#2
 EMPLOYER:
ADDRESS:
TELEPHONE:
SUPERVISOR:
DATES EMPLOYED:
TITLE OR POSITION:
DESCRIPTION OF JOB DUTIES:
REASON FOR LEAVING:
MAY WE CONTACT THIS EMPLOYER?:

 

#3
 EMPLOYER:
ADDRESS:
TELEPHONE:
SUPERVISOR:
DATES EMPLOYED:
TITLE OR POSITION:
DESCRIPTION OF JOB DUTIES:
REASON FOR LEAVING:
MAY WE CONTACT THIS EMPLOYER?:

 

#4
 EMPLOYER:
ADDRESS:
TELEPHONE:
SUPERVISOR:
DATES EMPLOYED:
TITLE OR POSITION:
DESCRIPTION OF JOB DUTIES:
REASON FOR LEAVING:
MAY WE CONTACT THIS EMPLOYER?:

EMPLOYMENT APPLICATION (Continued)

DATE YOU ARE AVAILABLE TO START:
DO YOU HAVE A CAR TO USE DURING WORK HOURS, IF NEEDED?
DO YOU HAVE A NEW YORK STATE DRIVER'S LICENSE?
DO YOU HAVE A CLEAN DRIVING RECORD?
IF NOT, LIST CONVICTION(S):

PLEASE NOTE: ALL STAFF MUST BE ABLE TO DRIVE AGENCY VEHICLES

HAVE YOU BEEN CONVICTED OF A CRIME?
IF YES, LIST CONVICTIONS:
ARE YOU CURRENTLY CERTIFIED IN CPR OR FIRST AID TRAINING?

LIST THREE PERSONAL REFERENCES (EXCLUDING RELATIVES)

NAME
ADDRESS
TELEPHONE
YEARS KNOWN

USE THIS SPACE FOR FURTHER EXPLANATION OR COMMENTS YOU WOULD LIKE TO MAKE:

BY CLICKING ON THE "SUBMIT" BUTTON BELOW YOU ARE CERTITYING THAT THE ABOVE INFORMATION, TO THE BEST OF YOUR KNOWLEDGE, IS TRUE AND ACCURATE AND ANY FALSE OR OMITTED INFORMATION WILL BE GROUNDS FOR DENIAL FO EMPLOYMENT OR LATER TERMINATION.