First Name*
Last Name*
Email Address*
Phone*
Who referred you to this position? Enter their first and last name here.
References: Please enter names and contact information:*
Have you previously worked for Anderson Center for Autism?*
-- No answer -- Yes No
If you answered yes to the previous question, please provide detail as to when.
Do you have any family members who are currently employed/have been employed by this company? Please provide their name below. If none, please enter "N/A".*
Please list any other names you have been known under (e.g. Maiden name, legal name change, etc.). If you have not gone by any other name, please enter "N/A".*
Are you legally authorized to work in the U.S.?*
-- No answer -- Yes No
Please indicate the highest level of education you've completed.*
-- No answer -- Some High School High School Diploma or GED Equivalent Some College/Currently Enrolled Associates Degree Bachelor's Degree Masters or Advanced Degree Doctoral Degree
Please describe your reasons for leaving previous jobs.*
May we contact your current employer?*
-- No answer -- Yes No
What is your desired salary?
Do you have a valid license to drive a car?*
-- No answer -- Yes No
If yes, in what state is your driver's license issued?*
Have you ever had your license suspended?*
-- No answer -- Yes No
If you answered yes to the previous question, please provide details here.
Have you ever had a drivers license revoked?*
-- No answer -- Yes No
If you answered yes to the previous question, please provide details here.
Have you ever had a DWI/DWUI/DWAI?*
-- No answer -- Yes No
If you answered yes to the previous question, please provide details here.
Have you ever had an accident that result in injury to anyone or property damage?*
-- No answer -- Yes No
If you answered yes to the previous question, please provide details here.
Section 424-a of the NYS Social Services Law requires that persons applying for employment with Child Care agencies be cleared with the State Central Registry to determine if they are the subject of an indicated child abuse or maltreatment report. Have you ever had an indicated (founded) case of child abuse, maltreatment, or neglect filed against you?*
-- No answer -- Yes No
If you answered yes to the previous question, please provide details here.
Please provide accurate and complete information in response to the following questions. This information will be taken into account in the employment process. (Please note that a criminal record with not necessarily disqualify you from employment.) Have you ever been convicted of a felony or misdemeanor? (Include military service conviction).*
-- No answer -- Yes No
If you answered yes to the previous question, please provide an explanation, disposition, and dates convicted.
Do you currently have felony or misdemeanor charges pending?*
-- No answer -- Yes No
If you answered yes to the previous question, please provide details here.
Have you ever had a final decision made against you, such as "Indicated", "Substantiated", or "Confirmed" allegation of abuse, maltreatment, or neglect by OPWDD, OCFS, Child Protective Services, Adult Protective Services, SED, or any other agency?*
-- No answer -- Yes No
If you answered yes to the previous question, please provide details here.
Were you ever, or are you now, excluded from participating in any State or Federal programs such as Medicaid or Medicare due to fraud or any other violations?*
-- No answer -- Yes No
If you answered yes to the previous question, please provide details here.
I, as part of this application for employment at Anderson Center for Autism, hereby authorize all companies, education institutions, persons, law enforcement agencies, military services, former employers, and others who may have data required by Anderson Center for Autism, to release information in their possession which they may have about me for the sole purpose of verifying this application of employment, and I hereby release and waive any and all claims against the persons or companies so requested from any liability or responsibility for the consequences of the release of information requested by Anderson Center for Autism.*
-- No answer -- Yes No
All of the statements within this employment application are true to the best of my knowledge and may be investigated by Anderson Center for Autism. I understand that any false statement or willful omission in this application will cause rejection or dismissal and that my employment is contingent upon satisfactory references. I acknowledge that if offered a position with Anderson Center for Autism, I will be required to submit to a Drug Screening, and a failed drug screening may result in the withdrawal of an employment offer. Anderson Center for Autism is an at-will employer and has the right to terminate employment at any time.*
-- No answer -- Yes No