Employment Application

We consider applicants for all positions without regard to race, color, religion, sex, national origin, age, sexual orientation, marital or veteran status, the presence of a non-job-related condition or any other legally protected status.

WJCS IS AN EQUAL OPPORTUNITY EMPLOYER
How Did You Learn About Us?
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 Friend
 Walk-in
 Employment Agency
 Relative
 Other

General Information
Position Applying For:
First Name
Middle Name
Last Name
Address
Addess 2
City
State
Zip
Home Phone
Cell Phone
Work Phone
Email

Availability
Type of Work
 Full time  Part time  On Call
 

Hours you can work:
  From To
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Questions
1. If you are under 18 years of age, can you provide required proof of eligibility to work?
 Yes  No
 
2. Have you ever filed an application or worked for us before?
 Yes  No
 
    If yes, please provide date
3. Are you currently employed?
 Yes  No
 
4. Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status?
(Proof of citizenship or immigration status will be required upon employment)
 Yes  No
 
5. Are you currently on “lay-off” status and subject to recall?
 Yes  No
 
6. Can you travel if a job requires it?
 Yes  No
 
7. Have you been convicted of a misdemeanor or felony?
 Yes  No
 
    If yes, please explain
8. Have you ever been founded for a substantiated allegation of abuse/neglect in any of your previous employment positions?
 Yes  No
 
    If yes, state charge(s) and date(s)
9. Do you have any pending misdemeanor or felony arrests?
 Yes  No
 
    If yes, state charge(s) and date(s)

Conviction will not necessarily disqualify an applicant from employment

Employment Experience

Start with your present or last job. Include any job-related military service assignments and volunteer activities. You may exclude organizations, which include race, religion, gender, national origin, handicap or other protected status.
Employer
Address
Phone
Supervisor
Dates of Employment
Salary
Describe your work
Why did you leave?
May we contact this employer?
 Yes  No  
Employer
Address
Phone
Supervisor
Dates of Employment
Salary
Describe your work
Why did you leave?
May we contact this employer?
 Yes  No  
Employer
Address
Phone
Supervisor
Dates of Employment
Salary
Describe your work
Why did you leave?
May we contact this employer?
 Yes  No  
List any other experiences, skills, or qualifications that you feel would especially fit you for work with our organization.

Education
High School Name
Years Completed
 9  10  11  12
 
Diploma/Degree
Undergraduate College/University
Years Completed
 1  2  3  4
 
Diploma/Degree
Graduate/ Professional
Years Completed
 1  2  3  4
 
Diploma/Degree
Describe any honors you have received

Indicate any foreign languages you can speak, read and/or write

  Fluent Good Fair
Speak
Read
Write

References

Personal References (Not Former Employers or Relatives)
Name
Address
Phone
Name
Address
Phone
Name
Address
Phone

Professional References
Name
Address
Phone
Name
Address
Phone
Name
Address
Phone
You also may upload your resume (PDF or Word)

For All Residential (Clinical and Direct Care) Positions and Staff Who Will be Driving Agency Vehicles
Do you have a valid New York State Driver’s License?
 Yes  No
 
If Yes, have you had any convictions related to moving violations within the past three (3) years and any suspensions, revocations, DWI convictions or occurrence involving harm to anyone or property while driving. Please describe

All licenses will be checked after the offer of employment.

For Clinical Applicants Only:
Statement of Professional Ethics and Conduct

1. Please indicate professional license held, if applicable
2. Have you ever been found by any professional association to which you have belonged to have violated its ethical code, or are you currently under investigation for an ethical violation by any other professional organization to which you belong? York State Driver’s License?
 Yes  No
 
3. Have you ever had your registration, certificate or license to practice you profession suspended, revoked, restricted, or denied or has any other disciplinary action been taken against you by any federal or state regulatory body or foreign jurisdiction or are you presently under investigation by any regulatory body, to the best of your knowledge?
 Yes  No
 
4. Have you ever had your privileges to practice your profession in a hospital, HMO, etc., suspended or restricted or has any other disciplinary action been taken against you on grounds of unprofessional conduct, incompetence, negligence, or unsafe practices?
 Yes  No
 
5. Have you ever voluntarily given up privileges, registration, certificate or license to practice your profession, or agreed to restrict your practice in lieu of or to avoid formal action?
 Yes  No
 
If you answered yes to any of the above, please provide detailed information.
6. Do you affirm that you are a member in good standing of your primary professional association (if appropriate)?
 Yes  No
 

For Staff Who Will Work with Children
I hereby certify that, to the best of my knowledge, I have never been "indicated" for child abuse and maltreatment in New York State or any other jurisdiction. I understand that I must complete a State Central Registry form and be cleared by the State Central Registry on Child Abuse and Maltreatment.

For Staff Who Will Work in School Based and Child Care Programs
I understand that New York State requires finger-printing clearance for employment in a school.

Applicant's Statement

I certify that answers given herein are true and complete to the best of my knowledge.

I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

I authorize WJCS to obtain information about me from my previous or current employers. I authorize my previous and/or current employers to provide WJCS with such information as they may request. In order to encourage full and candid disclosure, I further agree to hold harmless my previous and current employers and WJCS from any and all claims arising from the disclosure or use of any information related to my past or current employment to the extent permitted by law.

This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.

In the event of employment, I understand that false or misleading information given in my application or interview(s)is grounds for immediate dismissal. I understand, also, that I am required to abide by all rules and regulations of the employer.

WJCS is an equal opportunity community based employer. WJCS does not discriminate in employment and no question on this application is used for the purpose of limiting or excluding any applicant's consideration for employment on a basis prohibited by local, state or federal law.
Name
Date
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