AN EQUAL OPPORTUNITY EMPLOYER M/F/V/H
APPLICATION FOR EMPLOYMENT
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  Applicants are considered for all positions without regard to race, color, religion, sex, national origin, age marital or veteran status or the presence of a non-job-related medical condition or disability
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_{(PLEASE PRINT)NOTE: All questions must be answered completely or application will not be processed.}

_{Date of Application_____________}

_{Position(s) Applied For: ________________________________________________________________________________}

_{Referral Source:} q_{Advertisement}     q_Friend    q_Relative   q _Walk-in   q _{Employment Agency}    q _Other
Do any of your friends or relatives, other than your spouse, work here?     qYes    qNo_____________________________
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Name____________________________________________________________________________________________            (LAST)                                                             (FIRST)                                                             (MIDDLE)

Address _____________________________________________________________________________________________
                (NUMBER)         (STREET)                                     (CITY)                                     (STATE)                     (ZIP)

Telephone (            )_____________________________________   Social Security Number ________/________/________
        (AREA CODE)

Have you filed an application here before?  qYes    qNo     If yes, give date _____________________________________

Have you ever been employed here before? qYes   qNo     If yes, give date _____________________________________
Are you employed now?        qYes    qNo         May we contact your present employer?     qYes    qNo
On what date would you be available for work? _____________________________________________________________
Are you available to work        qFull Time        qPart Time        qShift Work        qTemporary
Are you on a lay-off and subject to recall?    qYes    qNo         Can you travel if job requires?     qYes    qNo
Do you have a valid New York State Drivers License? qYes    qNo     Do you have an out-of-state license? qYes    qNo
Have you received any moving violations in the past 8 years?     qYes    qNo    If yes, give details__________________

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Have you ever had any suspension, revocation, DWI, convictions, or any occurrence involving harm to anyone or property while driving?     qYes    qNo
If yes, explain ________________________________________________________________________________________

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Are you a Veteran of the U.S. Military service?    qYes     qNo        If yes, Branch ________________________________
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.)    qYes    qNo
If yes, give Alien Registration Number ____________________________________________________________________
Have you ever been convicted of a crime?    qYes     qNo
If yes, please explain, identifying the conviction, place and date _______________________________________________
No applicant will be excluded from consideration for employment due to prior arrests or convictions.