Employment Opportunities

Fill out the form below to submit your application to HASC Center.

			Date:	07/30/2010
PERSONAL INFORMATION
Last Name:	First:		Middle:
Mailing Address:
City:	State:		Zip:
Home Phone:		Work Phone:
Email Address:

If under 18 years old please indicate age:

Previous Residences:

Address:

From:

To:

Address:

From:

To:

Address:

From:

To:

Position(s) Applied For:

Salary Desired:

F/T P/T Other

Hours Available:

Date Available To Begin Work:

Are you legally employable under U.S. Immigration Laws?

Yes No

Are you in the US on a visa?	Yes No	If Yes, indicate visa exp date:
		Please provide copy of visa to the Human Resources Office.

A NYS driver’s license is required for some positions.

Do you possess a valid driver’s license?

Yes No

State:

Have you ever been convicted of a DWI?

Yes No

Date:

Do you have any moving violations?

Yes No

Date:

Have you applied for employment with HASC Center or any of its affiliates?	No Yes	Date:
Have you ever been employed here before?	No Yes	Date:
Are you employed now?	No Yes
May we contact your present employer?	No Yes
Are you on layoff or subject to recall?	No Yes
Are you currently attending school?	No Yes

Have you ever been convicted of a misdemeanor or a felony?	No Yes	Date:
Provide a description of all convictions:
Is there a pending criminal charge against you?	No Yes	Date:
Provide a description of all pending criminal charges:

EDUCATIONAL INFORMATION
Do you posses a high school degree or equivalency diploma?		Yes No
High School Name	City/State:
Date of Graduation or Expected Date of Graduation:
College/University:	City/State:
Years Completed:	Graduated:	Yes No
Expected Graduation Date:
Degree Received:	Major:
Second Major:	Minor:

College/University:	City/State:
Years Completed:	Graduated:	Yes No
Expected Graduation Date:
Degree Received:	Major:
Second Major:	Minor:
Other Degrees and/or Certifications: (Specify NYS Licenses where appropriate)
Computer Skills: Please list your familiarity with various software programs, operating systems and environments (i.e. DOS, UNIX, Windows, Local Area Networks, and Mainframes.)

EMPLOYMENT EXPERIENCE List below your employment history starting with the most recent employer. Include any period n which you were not employed and explain what you were doing during that time.
Employer:	Dates Employed: From: To:
Salary:
Address:
Position Held:
Reason for Leaving:
Supervisor:	Telephone Number:
Describe Duties:

Employer:	Dates Employed: From: To:
Salary:
Address:
Position Held:
Reason for Leaving:
Supervisor:	Telephone Number:
Describe Duties:

Employer:	Dates Employed: From: To:
Salary:
Address:
Position Held:
Reason for Leaving:
Supervisor:	Telephone Number:
Describe Duties:

PROFESSIONAL REFERENCES HASC requires 2 professional and 2 personal references. Please include 2 individuals who have had direct supervisory responsibility for your position as well as 2 individuals who are not related to you for personal references.
(1) Name:		Employment Relationship:
Employer:		Phone Number:

(2) Name:		Employment Relationship:
Employer:		Phone Number:

(3) Name:		Personal Relationship:
Occupation:		Phone Number:

(4) Name:		Personal Relationship:
Occupation:		Phone Number:

Attach your resume (required)

Comments:

APPLICANT’S STATEMENT

I certify that the information contained in this application is true and correct to the best of my knowledge and understand that falsification or omission of information is grounds for refusal to hire or, if hired, immediate termination.

I further authorize the investigation of all information in this application for employment as may be necessary in arriving at an employment decision.

I further understand that if employed, I am employed at-will and that my employment can be terminated at my option or the option of the agency at any time and that no employee or representative of the agency, other than the Chief Executive Officer or Chief Operating Officer, has any authority to enter into any agreement or contract contrary to the above.

I also agree that I am required to conform to the policies, procedures, rules and regulations of the agency and that all offers of employment are conditioned on the satisfactory proof of my identity and legal authority to work in the United States.

Print Name: Date:

HASC Center Inc. is an equal opportunity employer. Applicants are considered without regard to race, creed, color, national origin, sex, age, disability, marital status, sexual orientation, veterans’ status, citizenship status, or any other protected characteristic or status in all employment decisions, including but not limited to recruitment, hiring, compensation, training, promotion, transfers, termination, and all other terms and conditions of employment.
Please be aware that, if the position for which you are applying requires regular and substantial unsupervised or unrestricted physical contact with people being served by HASC Center, you will need to provide information, statements, and fingerprints according to the requirements of OMRDD regulations in order for a criminal background check to be conducted.