Employment Form

45 Prospect Avenue
Albany NY 12206
P: 518-435-9300
F: 518-435-1901

Programs, services and employment are equally available to everyone. Please inform the Human Resources Department if you require reasonable accommodation for the application or interview.

Applicant Data

* Full Name: * Position Applied for:
* Address: * City: * State: * Zip:
* Phone: Phone 2:
Email: SSN:
Date to Start: Salary Desired:
If you are under 18 years of age, can you provide a work permit? YES   NO
- If no, explain:
Have you ever worked for this company: YES   NO
- If yes, when?:
Are you legally allowed to work in the United States? YES   NO
Type of employment desired: Full-Time   Part-Time   Temporary   Seasonal  
Have you ever pleaded guilty, no contest or been convicted of a crime? YES   NO
- If yes, give dates and details:
Answering yes to these questions does not constitute an automatic rejection for employment. Date of the offense, seriousness and nature of the violation, rehabilitation and position applied for will be considered.
Driver's license number (if applicable to position): State :

Summarize Your Special Skills or Qualifications

Previous Employment (begin with most recent position)

Dates of Employment: From: To: Position(s) Held:
Company Name:
Address: City: State: Zip:
Phone: Supervisor: Title:
Responsibilities:
Starting Salary and Title: Ending Salary and Title:
Reason for Leaving:
May we contact this employer for a reference: YES   NO
Dates of Employment: From: To: Position(s) Held:
Company Name:
Address: City: State: Zip:
Phone: Supervisor: Title:
Responsibilities:
Starting Salary and Title: Ending Salary and Title:
Reason for Leaving:
May we contact this employer for a reference: YES   NO
Dates of Employment: From: To: Position(s) Held:
Company Name:
Address: City: State: Zip:
Phone: Supervisor: Title:
Responsibilities:
Starting Salary and Title: Ending Salary and Title:
Reason for Leaving:
May we contact this employer for a reference: YES   NO

I certify that my answers are true and complete to the best of my knowledge. I authorize you to make such investigations and inquiries of my personal, employment, educational, financial and other related matters as may be necessary for an employment decision. I hereby release employers, schools or individuals from all liability when respond to inquires in connection with my application.

In the event I am employed, I understand that false or misleading information given in my application or interview(s) may result in discharge.

* By checking this box you understand and agree to the above statements: