Employment ApplicationL.E.A.P. Employment ApplicationIt 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 MM slash DD slash YYYY How Did You Learn About Us? L.E.A.P. WEBSITE Online ad Friend/Relative OtherPreferred Pronoun He/Him She/Her They/Them Ze/HirName First Middle Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country PhoneEmail Have you ever filed an application with us before Yes NoIf Yes, give dateHave you ever been employed with us before? Yes NoIf Yes, give dateAre you currently employed? Yes NoMay we contact your present employer? Yes NoAre 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 NoOn what date would you be available for work?Are you available to work? Full Time Part Time BothAre you currently on “lay-off” status and subject to recall? Yes NoCan you travel if a job requires it? Yes NoHave you been convicted of a crime (felony or misdemeanor) within the last 7 years? Conviction will not necessarily disqualify an applicant from employment. Yes NoIf Yes, please explain:EDUCATIONHigh School - Name and AddressCourse of StudyYears CompletedDiploma/DegreeUndergraduate College - Name and AddressCourse of StudyYears CompletedDiploma/DegreeGraduate Professional - Name and AddressCourse of StudyYears CompletedDiploma/DegreeOther (Specify)Course of StudyYears CompletedDiploma/DegreeDescribe any specialized training, apprenticeship, job related skills and qualifications:EMPLOYMENT EXPERIENCEStart 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. EmployerAddressJob TitleSupervisorDates Employed (From-To)Work PerformedReason for Leaving2. EmployerAddressJob TitleSupervisorDates Employed (From-To)Work PerformedReason for Leaving3. EmployerAddressJob TitleSupervisorDates Employed (From-To)Work PerformedReason for LeavingState 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 NoAre 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 NoIf No, please explainDo you have a valid New York State driver’s license without any motor vehicle violations during the past 18 months? Yes NoREFERENCES/CONSENT FOR RELEASE OF INFORMATIONI, (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 ApplicantDate MM slash DD slash YYYY