Application For Employment


We appreciate your interest in our organization. A clear understanding of background and work history will help us place you in a mutually beneficial job position. We consider applicants for all positions without regard to race, color, creed, age, gender, sexual orientation, disability, marital status, military or veteran status, arrest/conviction record, national origin, genetic information, predisposition, or carrier status, domestic violence victim status or any other status protected by applicable law.

Personal Information

If you are under 18 years of age, can you furnish a work permit? Have you ever been employed by us before? *

Are you legally allowed to work in the U.S.? *

Are you able to perform the essential functions of the position for which you are applying, with or without reasonable accommodation?

Have you ever been convicted of or pled guilty to a felony, misdemeanor, violation, or other crime (other than a minor traffic violation)?

Are there any arrests or criminal accusations pending against you?

Note: Neither a conviction nor an arrest is an automatic bar from employment. Each case is considered and evaluated on its individual merits in relation to the duties and responsibilities of the position.

Have you ever been sanctioned or otherwise disciplined by, or excluded from, the New York Medicaid Program, Medicare or any other state or federal government funded program?





Please attach copies of current professional certificates/licenses.

Have you ever been investigated by, or subject to a disciplinary proceeding by a professional licensure or disciplinary agency (such as the Office of Professional Discipline, the Office of Professional Medical Conduct, or the Department of Health), in New York or in any other state?

REFERENCES: Give name, address and a telephone number of three references not related to you who are qualified to evaluate your capabilities and are not previous employers.

Availability Form:

Please write below what times you would be available to work as well as times you are not available to be scheduled to work.








Employment Experience

List below your last five employers, beginning with the most recent.
Please sign the two Employment Reference Checks that are attached to this application.

Applicant's statement:

I understand that neither this application, any statements made by any employer representatives, nor any offer of employment constitutes an employment contract. I understand that should an offer of employment be extended, that employment will be “at will”, for no specified duration and may be terminated by myself or the employer at any time, with or without cause. I also understand that no employer representative has the authority to enter into an employment contract, guarantee employment for a specified period, or modify any of the foregoing, other than in a written document signed by the Director of Human Resources or designee.

I certify that the information provided in and incorporated by reference into this application and all other information I provide during the hiring process is true, accurate and complete and authorize employer to investigate such. I further understand that any misrepresentation or omission may be justification for rejection of my application or cause for terminating my employment at any time, regardless of the timing or circumstances of discovery