Employment Application

L.E.A.P. Employment Application

It is our policy to fill vacancies with the best qualified candidate. We do not discriminate in hiring or employment procedures against an applicant in regard to race, color, creed, gender, national origin, age, disability, marital or veteran status, sexual orientation, or any other legally protected status. (PLEASE PRINT OR TYPE)

Position(s) Applied For:

Date

How Did You Learn About Us?

L.E.A.P. WEBSITE

Online ad

Friend/Relative

Other

Preferred Pronoun

He/Him

She/Her

They/Them

Ze/Hir

Name

First Middle Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Have you ever filed an application with us before

Yes

If Yes, give date

Have you ever been employed with us before?

Yes

If Yes, give date

Are you currently employed?

Yes

May we contact your present employer?

Yes

Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status? (Proof of citizenship/immigration status will be required upon employment).

Yes

On what date would you be available for work?

Are you available to work?

Full Time

Part Time

Both

Are you currently on “lay-off” status and subject to recall?

Yes

Can you travel if a job requires it?

Yes

Have you been convicted of a crime (felony or misdemeanor) within the last 7 years? Conviction will not necessarily disqualify an applicant from employment.

Yes

If Yes, please explain:

EDUCATION

High School - Name and Address

Course of Study

Years Completed

Diploma/Degree

Undergraduate College - Name and Address

Course of Study

Years Completed

Diploma/Degree

Graduate Professional - Name and Address

Course of Study

Years Completed

Diploma/Degree

Other (Specify)

Course of Study

Years Completed

Diploma/Degree

Describe any specialized training, apprenticeship, job related skills and qualifications:

EMPLOYMENT EXPERIENCE

Start with your present or last job. Include any job-related military service assignments and volunteer activities. You may exclude organizations that indicate race, color, religion, gender, national origin, disabilities or other protected status.

1. Employer

Address

Job Title

Supervisor

Dates Employed (From-To)

Work Performed

Reason for Leaving

2. Employer

Address

Job Title

Supervisor

Dates Employed (From-To)

Work Performed

Reason for Leaving

3. Employer

Address

Job Title

Supervisor

Dates Employed (From-To)

Work Performed

Reason for Leaving

State any additional information you feel may be helpful to us in considering your application.

Note to applicants: DO NOT ANSWER THIS QUESTION UNLESS YOU HAVE BEEN INFORMED ABOUT THE REQUIREMENTS OF THE JOB FOR WHICH YOU ARE APPLYING.

Are you capable of performing in a reasonable manner the activities involved in the job or occupation for which you have applied? A description of the activities involved in such a job occupation is attached.

Yes

Are you able to perform all of the essential job functions of the position without reasonable accommodations, and if not, what functions can’t you perform?

Yes

If No, please explain

Do you have a valid New York State driver’s license without any motor vehicle violations during the past 18 months?

Yes

REFERENCES/CONSENT FOR RELEASE OF INFORMATION

I, (type name below) hereby give L.E.A.P. permission to contact the following people to obtain employment reference information.

First Last

Name of Professional Reference:

Address:

Phone Number:

Title of Reference /Affiliated With:

Name of Professional Reference:

Address:

Phone Number:

Title of Reference /Affiliated With:

Name of Personal Reference:

Address:

Phone Number:

Title of Reference /Affiliated With:

I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. I authorize contact with any prior or current employers unless specifically noted in writing. I authorize the references I have provided, and any prior or current employers, to disclose any information related to my work history, performance, and experience without giving me any prior notice of each disclosure. I release the Employer from any and all claims, demands or liability arising out of or in any way related to obtaining such information about me or investigating any aspect of this employment application. I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an “at will” nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause, pending Board/ Policy Council approval if applicable. It is further understood that this “at will” employment relationship may not be changed by any written document or by conduct unless such a change is specifically acknowledged in writing by any authorized executive of this organization. I swear that the information contained herein is true and complete to the best of my knowledge.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.

Signature of Applicant

Date