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EMPLOYMENTAPPLICATION ݌  Ќ<T<  XPXXXH  XX  K(XK  XHXXXP SENECACAYUGAARC  XXH182NorthStreetAuburn,NewYork130213152552285XHX  XXH1083WaterlooGenevaRoadWaterloo,NewYork131653155395067  www.sencayarc.org YL K(X K?+ ` hp x X?(PROSPECTIVEEMPLOYEESWILLRECEIVECONSIDERATIONWITHOUTREGARDTORACE,COLOR,CREED,GENDER, & AGE,NATIONALORIGIN,DISABILITY,MARITALORVETERANSTATUSORANYOTHERLEGALLYPROTECTEDSTATUS.  SENECACAYUGAARCISANEQUALOPPORTUNITYEMPLOYER XK K(XK(DATE__(_______________________    K(XW JKGENERAL e X  K(X K  K(X K LASTNAMEFIRSTNAMEMIDDLEINITIALSOCIALSECURITY   NUMBER J =   K(X! KK(X K PRESENTADDRESS(STREET,CITY,STATE,ZIPCODE)    K(X K K(X6) KHOMETELEPHONENUMBERALTERNATEPHONENUMBER B5 K(X  KK(X KAREYOULEGALLYAUTHORIZEDTOWORKINTHEUNITEDSTATES?(PROOFWILLBEREQUIREDUPON  EMPLOYMENT).YES_______NO___________ WJ K(X KK(X.! KHAVEYOUEVERBEENCONVICTEDOFAMISDEMEANORORAFELONYINANYJURISDICTIONWHICHHASNOTBEEN :- ANNULLED,EXPUNGED,ORSEALEDBYACOURT,ORHAVECRIMINALCHARGESPENDING?YES____NO____  If:(@(:YES:(@(:,GIVEDATE,JURISDICTION,CHARGE,ANDDISPOSITION. l_  K(XE8 KK(XKHAVEYOUEVERWORKEDFORCAYUGAARC,_CTC_,SENECAARCoranyother_NYSARC_ԀChapter? $ YES_____________NO_____________ v% IFYES,GIVEAGENCY,DATES,POSITIONandREASONFORLEAVING: & K(X KK(XKAREYOUCURRENTLYEMPLOYED?YES____________NO_______________ * K(X=0 KK(XK  POSITION , K(X~K  ӀPOSITIONAPPLYINGFOR: - Ѐ 0 #. WEREYOUREFERREDTOTHISAGENCYBYACURRENTEMPLOYEE?_____IFSO,WHO?  / ___________________________ b!U0 ЀSALARYREQUIREMENTS: !1 K(X9#,! K  AVAILABILITY G#:!3 K(X#!K  Pleaseindicateworklocationsthatareacceptable:____CAYUGACOUNTYPROGRAMS____SENECACOUNTY #!4 PROGRAMS $"5 Pleaseindicateshifts/schedulesthatareacceptable:____DAYS____EVENINGS___NIGHTS____ROTATING %#7 _____SPLIT ^&Q$8 Ѐ_____FULLTIME__________PARTTIME________RELIEF/SUB________TEMPORARY &$9 K(X'% K  MOTORVEHICLEOPERATORINFORMATION '%: K(XQ(D&K  DOYOUHAVEAVALIDDRIVERSLICENSE?YES_______________NO_________________ ](P&; IFYES,ISSUEDBYWHATSTATE?__________________________________________________ )'= HAVEYOUEVERHADYOURLICENSESUSPENDEDORREVOKED?YES________NO_______ *(? HAVEYOUBEENCONVICTEDOFAMOVINGVIOLATIONWITHINTHEPASTEIGHTYEARS?_________ +)A IFYES,PLEASEEXPLAIN %-+C  -+D ЇK(X K (  K(XK?+ ` hp x X?    EMPLOYMENTHISTORY:Beginningwiththemostrecent,listyourlastthree(3)employers(including  militaryorvolunteerexperience).Resumesmaynotbeusedasasubstituteforcompletingthissection,݌ aT ЌR/X48R( ((  XX  K(XK (EMPLOYER * ____________________________________________________________________________________________  StreetAddress: w ____________________________________________________________________________________________ 1$ City/State/Zip: Telephone:  ___________________________________________________________________________________________ ~ StartDate:EndDate:Salary:Title: 8+  ____________________________________________________________________________________________   Supervisor  =  sName:Supervisor  =  sTitle:    ____________________________________________________________________________________________ A 4  Reasonforleaving:     ____________________________________________________________________________________________    Maywecontactforreference?________YES_____NO H ;  ____________________________________________________________________________________________   EMPLOYER: OB  ____________________________________________________________________________________________   StreetAddress:   ____________________________________________________________________________________________ VI City/State/Zip:Telephone:  ____________________________________________________________________________________________  StartDate:EndDate:Salary:Title: ]P ____________________________________________________________________________________________   Supervisor  =  sName:Supervisor  =  sTitle:  ____________________________________________________________________________________________ fY Reasonforleaving:  ___________________________________________________________________________________________  Maywecontactforreference?___________YES______NO m` ____________________________________________________________________________________________   EMPLOYER: tg! ____________________________________________________________________________________________ !" 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IGIVETHEEMPLOYERTHERIGHTTOINVESTIGATEALLREFERENCES,ANDTOSECUREADDITIONAL  o  INFORMATIONABOUTMEIFJOBRELATED.IUNDERSTANDTHATSENECACAYUGAARCIS    REQUIRED/AUTHORIZEDBY_NYS_ԀLAWTOREQUESTACHECKOFMYCRIMINALHISTORYRECORDANDTO y   REVIEWTHERESULTSOFTHECHECK.IHEREBYRELEASEFROMLIABILITYTHEEMPLOYERANDIT  =  S &v  REPRESENTATIVESFORSEEKINGSUCHINFORMATION,ANDALLOTHERPERSONS,CORPORATIONSOR %  ORGANIZATIONSFORFURNISHINGSUCHINFORMATION.   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