Employment Application Step 1 of 7 14% GENERALPOSITION APPLIED FOR: OTHER TYPE OF WORK DESIRED: SALARY REQUIRED: DATE OF APPLICATION: MM slash DD slash YYYY TYPE OF EMPLOYMENT:FULL TIMEPART TIMETEMPORARY/SEASONAL. SUMMERDATE AVAILABLE TO START WORK: MM slash DD slash YYYY HOW DID YOU HEAR ABOUT US?Choose OneJob BoardEmployee ReferralNewspaperSocial MediaOther"OTHER" REFERRAL SOURCE STATE THE NAMES OF ANY FRIENDS OR RELATIVES, EXCLUDING A SPOUSE, CURRENTLY EMPLOYED BY BRIDGES:One name per lineHAVE YOU EVER BEEN EMPLOYED BY BRIDGES?Choose OneYesNoPOSITION HELD/DATES REASON FOR LEAVING: PERSONAL DATAName First Middle Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email Cell PhoneHome PhoneARE YOU LEGALLY AUTHORIZED TO WORK IN THE U.S.?Choose OneYesNoIF ANY RECORDS ARE UNDER ANY NAME OTHER THAN SHOWN, PLEASE INDICATE: DO YOU HAVE A DRIVER’S LICENSE?Choose OneYesNoIf yes, please be prepared to produce your license during the interview.Gender Please type the gender you identify as:EthnicityAsian (Not Hispanic or Latino)Black or African American (Not Hispanic or Latino)Hispanic or LatinoNative American or Alaska Native (Not Hispanic)Native Hawaiian or Other Pacific IslanderTwo or More Races (Not Hispanic or Latino)White (Not Hispanic or Latino)Chose not to answerHAVE YOU EVER BEEN A MEMBER OF THE ARMED FORCES OF THE UNITED STATES?Choose OneYesNoIF YES, PLEASE INDICATE BRANCH: DATE OF SERVICE: SPECIAL TRAINING OR EXPERIENCE RELATED TO THE POSITION FOR WHICH YOU ARE APPLYING:HAVE YOU HAD ANY PRIOR OR CURRENT EXPERIENCE AS AN EMPLOYEE, VOLUNTEER, OR CERTIFIED PROVIDER WITH OPWDD OR OMH; ANY OTHER STATE AGENCY; OR ANY OTHER PROVIDER OF HUMAN SERVICES?Choose OneYesNoHAVE YOU HAD ANY PRIOR OR CURRENT EXPERIENCE IN CHILD-CARE?Choose OneYesNoHAVE YOU HAD ANY PRIOR OR CURRENT EXPERIENCE IN DIRECT CARE WORK?Choose OneYesNoHAVE YOU EVER BEEN EXCLUDED FROM PARTICIPATION IN ANY FEDERALLY SPONSORED HEALTH CARE PROGRAMS, INCLUDING BUT NOT LIMITED TO, MEDICAID AND MEDICARE?Choose OneYesNoPLEASE PROVIDE THE NAMES, ADDRESSES AND TELEPHONE NUMBERS OF REFERENCES WHO CAN VERIFY EACH EXPERIENCE:One per line CRIMINAL RECORDHAVE YOU EVER BEEN CONVICTED OF OR ARE YOU AWAITING TRIAL DISPOSITION ON A FELONY, MISDEMEANOR OR SUMMARY OFFENSE IN ANY JURISDICTION AND/OR DO YOU HAVE ANY PENDING CRIMINAL CHARGES, ARRESTS, OR CRIMINAL ACCUSATIONS AGAINST YOU?Choose OneYesNoCONVICTIONS WILL NOT AUTOMATICALLY DISQUALIFY JOB CANDIDATES. DATE OF CONVICTION AND SEVERITY WILL BE CONSIDERED. Please be advised that BRIDGES is required by law to request and review any criminal history information for persons performing certain job duties within the Agency. If the position you are applying for requires this background check, you will be required to provide information, statements and fingerprints according to legal requirements and the Agency shall request information concerning you from the Division of Criminal Justice Services, the Federal Bureau of Investigation, the Excluded Parties List Of the General Services Administration, the Office of the Inspector General and New York State. Also, you will have the right to Obtain, review and seek correction of criminal history information received in response to the criminal background check.IF YES, INCLUDE A DESCRIPTION OF ALL CONVICTIONS AND PENDING CRIMINAL CHARGES. STATE NATURE OF OFFENSES, WHEN, WHERE (EXACT LOCATION,) AND DISPOSITION:MOTOR VEHICLE DRIVING CERTIFICATION AND RECORD OF CONVICTIONSIf NO violations are listed above, I hereby certify that I have NOT been convicted of any moving violation, suspension, revocation, DWI, or any occurrence involving harm to any person or property. I understand the BRIDGES has the right to verify my record of convictions with the Department of Motor Vehicles. I fully understand that if this certification fails to disclose convictions or offenses, or inaccurately discloses such information, BRIDGES may justly terminate my employment or provisional employment. EDUCATION Please provide the name and location.HIGH SCHOOL GRADUATEDChoose OneYesNoYEARS ATTENDEDTYPE OF DEGREE COLLEGES UNIVERSITIES:INCLUDE FIELD OF STUDY AFTER THE INSTITUTIONGRADUATEDChoose OneYesNoYEARS ATTENDEDTYPE OF DEGREE VOCATIONAL SCHOOLSONE PER LINEGRADUATEDChoose OneYesNoYEARS ATTENDEDCERTIFICATE OR LICENSES OTHER RELATED HISTORY/ACTIVITIES/SKILLSSTATE PROFESSIONAL LICENSES AND WHERE REGISTERED, VOLUNTEER EXPERIENCE OR ANY OTHER SPECIAL TRAINING OR SKILLS YOU HAVE THAT RELATE TO THE TYPE OF SERVICES OUR AGENCY PROVIDES: EMPLOYMENT RECORD LIST YOUR ENTIRE EMPLOYMENT HISTORY. LIST MOST RECENT JOBS FIRST. INCLUDE FULL AND PART-TIME WORK, AND SELF-EMPLOYMENT. ATTACH ADDITIONAL SHEET(S) IF NECESSARY. THE ENTIRE PERIOD MUST BE ACCOUNTED FOR. EMPLOYER ADDRESS FROM TO JOB TITLE SUPERVISOR TELEPHONE NUMBERSALARYREASON FOR LEAVINGDUTIES PERFORMEDMAY WE CONTACT AT THE PRESENT TIME?Choose OneYesNoIF NOT, INDICATE WHEN: EMPLOYER ADDRESS FROM TO JOB TITLE SUPERVISOR TELEPHONE NUMBERSALARYREASON FOR LEAVINGDUTIES PERFORMEDMAY WE CONTACT AT THE PRESENT TIME?Choose OneYesNoIF NOT, INDICATE WHEN: EMPLOYER ADDRESS FROM TO JOB TITLE SUPERVISOR TELEPHONE NUMBERSALARYREASON FOR LEAVINGDUTIES PERFORMEDMAY WE CONTACT AT THE PRESENT TIME?Choose OneYesNoIF NOT, INDICATE WHEN: EMPLOYER ADDRESS FROM TO JOB TITLE SUPERVISOR TELEPHONE NUMBERSALARYREASON FOR LEAVINGDUTIES PERFORMEDMAY WE CONTACT AT THE PRESENT TIME?Choose OneYesNoIF NOT, INDICATE WHEN: ATTACH RESUME INPDF FORMAT PREFERREDAccepted file types: png, pdf, docx, Max. file size: 3 MB.Maximum file size - 3 mega bytes. BUSINESS-PERSONAL REFERENCES AND RELEASE BUSINESS REFERENCES:PLEASE LIST ALL PAST OR CURRENT IMMEDIATE SUPERVISORS, INCLUDING YOU LAST PLACE OF EMPLOYMENT. PLEASE DO NOT INCLUDE RELATIVES OR BRIDGES EMPLOYEES.BUSINESS NAME AND ADDRESSIMMEDIATE SUPERVISOR’S NAME AND TITLEPHONE NUMBER & EXTENSIONBUSINESS NAME AND ADDRESSIMMEDIATE SUPERVISOR’S NAME AND TITLEPHONE NUMBER & EXTENSIONBUSINESS NAME AND ADDRESSIMMEDIATE SUPERVISOR’S NAME AND TITLEPHONE NUMBER & EXTENSIONBUSINESS NAME AND ADDRESSIMMEDIATE SUPERVISOR’S NAME AND TITLEPHONE NUMBER & EXTENSIONPERSONAL REFERENCES: PLEASE PROVIDE TWO PERSONAL REFERENCES, INCLUDING TEACHERS, NEIGHBORS, AND VOLUNTEER ORGANIZATIONS WHO WILL ATTEST TO YOUR SUITABILITY TO WORK IN HUMAN SERVICES. PLEASE DO NOT INCLUDE RELATIVES OR BRIDGES EMPLOYEES.NAME AND ADDRESSORGANIZATION NAME OR RELATIONSHIP TO APPLICANTPHONE NUMBER & EXTENSIONNAME AND ADDRESSORGANIZATION NAME OR RELATIONSHIP TO APPLICANTPHONE NUMBER & EXTENSIONI hereby authorize the above business and personal reference to furnish BRIDGES with any information concerning my employment history, qualifications, work skills, and suitability to work in human services. I release the above from any liability in furnishing the requested information, and understand that this information will be kept confidential. APPLICANT CERTIFICATION I hereby state that all the information that I provided on this Application or any other document submitted in connection with my employment, and in any interview, are true and correct. I have withheld nothing that would, if disclosed, affect this Application unfavorably. I understand that if I am employed by BRIDGES and any information is later found to be false in any respect or if I have omitted material information, my employment may be terminated at BRIDGES’s discretion. I acknowledge that acceptance of this application affords no assurance of eventual employment and nothing herein shall create a contract of employment with BRIDGES. No offer of employment guarantees any specific duration of employment, as all employment with BRIDGES is at will -- employment and compensation can be terminated with or without notice, and with or without cause, at any time. I understand that if selected for hire, it will be necessary for me to provide satisfactory evidence of my identity and legal authority to work in the United States. I acknowledge that in order to verify the information I provided in this application, BRIDGES may be contacting my former employers. I authorize and request that any and all of my former employers and any other persons, or companies furnish BRIDGES with any and all information concerning my professional background and experience, and I release each such employer, entity or other person, from any and all liability by reason of furnishing the requested information. I am aware that all applicants and employees are covered by BRIDGES’s anti-discrimination and harassment policy and complaint procedures, which provides an avenue for individuals to complain about discriminatory conduct and have such complaints investigated and resolved. I am aware that copies of this policy are provided upon commencement of employment and/or upon request. I have been informed and understand that BRiDGES is required by law to request and review any criminal history information for persons performing certain job duties within the Agency. If the position I am applying for requires this background check, I will be required to provide information, statements and fingerprints and the Agency shall request information concerning me from the Division of Criminal Justice Services, the Federal Bureau of Investigation and the Excluded Parties List of the General Services Administration, the Office of the Inspector General and New York State. I understand and accept the fact that my criminal history information (if any) that is communicated to the Agency may result in my disqualification as a candidate for employment, or termination of my employment (if the results of the background check are completed after a job offer has been made). I further understand that I have the right to obtain, review and seek correction of my criminal history information and I have been informed of these rights. Upon the completion of the criminal background check, I will be informed of the procedures necessary to exercise these rights. BY SELECTING YES, THE APPLICANT CERTIFIES THAT THE INFORMATION PROVIDED IS ACCURATE: * Required YES NO