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Federal and state laws prohibit discrimination in employment because of sex, age, race, color, religious creed, marital status, national origin, ancestry, disability or handicap.

Instructions to Applicant: Please read carefully. Every item on this form must be answered to the best of your ability. Your qualifications will be reviewed and you will be given thorough consideration for any applicable vacancies. If you are employed by Heather Heights of Pittsford, Inc., this form will become a part of your personnel file.

Applicants are not required to give any information on this form that is prohibited by Federal, State or Local Law.
 Personal Information    
Social Security Number:
Your Full Name:
Your Address:
City:
State:
Zip:
Your E-mail:
Phone Number:
Mobile/Other:
18 Years Or Older:
Are you a citizen of the United States?
If NO, are you legally allowed to work in the United States? (Proof of citizenship or immigration status will be required upon employment.)
Have you ever been convicted of a crime?
If YES, give dates/details:
Position you are applying for:
Your Rate of Pay Expected:
Date you can start:
Have you ever applied to this company before:
If YES, when:
Have you ever worked for this company before:
If YES, when - please give Supervisor Name, Facility Name, Location of Facility & Reason for leaving:
Do you have any friends or relatives employed by this company?
If YES, Name, Relationship to you Facility Name, Location of Facility & Position:
Have you ever worked for this company under a different name?
If YES, what name?
Is any additional information related to a change of name, use of an assumed name, or nickname necessary to enable verification of your work record?
If YES, please explain:
Do you have any physical impediments that would impair your ability to perform the job applied for?
If YES, please describe:
Do you have a valid NY state driver's license?
If NO, please explain:
Have you received any moving violations in the past 8 years?
If YES, give dates/details:
Have you had any suspension, revocation, DWI, DWUI, convictions, or any occurrence involving harm to anyone or property while driving?
If YES, give dates/details:
Method of transportation to work:
What foreign languages do you speak, read and/or write fluently?
Indicate your availability:


Type of employment desired:


Are you on a layoff and subject to recall?
Can you travel if the job requires?
Are you involved in any activity which would interfere with regular work scheduling?
If YES, please explain:
Referral source:

Summarize Your Special Skills or Qualifications:
Are you currently employed?
If yes, may we contact your present employer?
Have you ever been discharged or asked to resign by any former employer?
If YES, please explain:
Military Record
Were you in the US Armed Forces?
Rank at discharge: (Please attach a copy of your DD Form 214).
Type of discharge:
List duties in the service including special training:
 

 Record of Employment 1 (begin with your present or last job)
Dates of Employment: From:   To:   
Positions(s) Held:
Employer Name:
Address of Employer:  
Employer Phone Number:  
Supervisor:  
Title of Supervisor:  
Your Responsibilities:  
Start Rate of Pay & Title:  
End Rate of Pay & Title:  
Reason for Leaving:  
May we contact this employer for reference ? Yes     No  
   
 Previous Employment 2
Dates of Employment: From:   To:   
Positions(s) Held:
Employer Name:
Address of Employer:  
Employer Phone Number:  
Supervisor:  
Title of Supervisor:  
Your Responsibilities:  
Start Rate of Pay & Title  
End Rate of Pay & Title  
Reason for Leaving:  
May we contact this employer for reference ? Yes     No  
   
 Previous Employment 3
Dates of Employment: From:   To:   
Positions(s) Held:
Employer Name:
Address of Employer:  
Employer Phone Number:  
Supervisor:  
Title of Supervisor:  
Your Responsibilities:  
Start Rate of Pay & Title    
End Rate of Pay & Title  
Reason for Leaving:  
May we contact this employer for reference ? Yes     No  
   
References
Full Name:
Company: 
Address:  
Relationship:  
Phone Number:  
   
Full Name:  
Company:  
Address:  
Relationship:  
Phone Number:  
 
Full Name:  
Company:  
Address:  
Relationship:  
Phone Number:  
   
Record of Education
Elementary School:  (Name and Address)
Course of Study
Last Year Completed:
Did you graduate:  
Diploma or Degree:  
   
High School: (Name and Address)  
Course of Study:  
Last Year Completed:
Did you Graduate:  
Diploma or Degree:  
 

College:  (Name and Address)
Course of Study
Last Year Completed:
Did you graduate:  
Diploma or Degree:  
   
Other: (Name and Address of School)  
Course of Study:  
Last Year Completed:
Did you Graduate:  
Diploma or Degree:  
   
Professional Licenses / Certifications (if any)
Type:
State(s) Valid:
Number:
Valid Since:
List Professional, Trade or Business Organizations to which you belong:
Emergency Contact
In case of emergency, please notify:
Relationship:
Address:
Phone:
Applicant's Statement

I understand that any employment by this agency will be on a 180-day probationary basis. If employed by this agency I agree to abide by all rules indicated in the company handbook, facility/property policies and procedures as well as applicable state regulations governing this agency/property. I further understand that this employment application is not and is not intended to be an employment contract. I certify that the above information is complete and true to the best of my knowledge. I understand that discovery of misrepresentation or omission of facts herein will be cause for immediate dismissal regardless of when this is discovered. I hereby authorize this agency to contact any and/or all of the references and former employers listed in this application for full information as may be necessary to an employment decision. I agree to take a physical examination at any time, at the request of this agency, and agree that the examining physician may disclose the findings to this agency or an authorized agent of this agency.

I agree to the Statement
      

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