Search Site

Employment Application - New Candidate

Pathways, Inc. 33 Denison Parkway West Corning, NY 14830
(607) 937-3200 Administrative Offices
(607) 937-3205 Human Resources fax

GENERAL INFORMATION

Date of Application:
Applicant Full Name:
Present Address (including city, state zip code):
How Long at Present Address? years

Home Phone Number:
Daytime Phone Number:
Cell Phone Number:
Email Address: (required)

Position Applying For:
Status Desired:
Shift Desired:

Program(s) of Interest: (Check all that apply)
Child Care
Mental Health
Developmental Disabilities
Traumatic Brain Injury/Nursing Home Transition and Diversion/Home Care Services

EDUCATION

High School Graduated?
College Graduated?
Graduate School Graduated?
License/Certification Type
License/Certification Number Effective Date Expiration Date

* Have you ever been convicted of a crime?
If yes, please explain.

* Are you now or have you ever been excluded from providing services under Medicaid?
* Are you at least 18 years of age?
* How did you hear about Pathways and this position?

* Have you ever applied for work at Pathways?
When & Where:
* Have you ever been employed by Pathways?
When & Where:

Reason for Leaving:

PERSONAL CHARACTER REFERENCES
(List Three Persons Other Than Relatives or Former Employers)

1) Name:
Daytime Telephone #
Address
Occupation:
Years Known:

2) Name:
Daytime Telephone #
Address
Occupation:
Years Known:

3) Name:
Daytime Telephone #
Address
Occupation:
Years Known:

VOLUNTEER/INTERNSHIP EXPERIENCE
Name of Agency:
Name of Contact:
Address:
Telephone #:
Timeframe:
Responsibilities:

SKILLS AND EXPERIENCE
(Please use the space below to state your skills, experience and why you feel that you are qualified for this position.)

MOST RECENT EMPLOYMENT EXPERIENCE

(List all information regarding your last three employers, beginning with present or most recent employer)

EMPLOYER NAME:
Supervisor Name, Title, Daytime Phone:
Salary (Start-Final):
Employment Period (MO/YR):
Describe Major Duties, Responsibilities, Accomplishments:
May we contact?
Employer's Address:
Employer's Telephone #
Job Title
Reason for Leaving

EMPLOYER NAME:
Supervisor Name, Title, Daytime Phone:
Salary (Start-Final):
Employment Period (MO/YR):
Describe Major Duties, Responsibilities, Accomplishments:
May we contact?
Employer's Address:
Employer's Telephone #
Job Title
Reason for Leaving

EMPLOYER NAME:
Supervisor Name, Title, Daytime Phone:
Salary (Start-Final):
Employment Period (MO/YR):
Describe Major Duties, Responsibilities, Accomplishments:
May we contact?
Employer's Address:
Employer's Telephone #
Job Title
Reason for Leaving

SPECIFIC EMPLOYMENT EXPERIENCE IN THIS FIELD

(List information for any other employment, other than the first three on the previous page, to show additional years of specific experience in this field. This information is critical to determining rate of pay, should you be offered employment with Pathways, Inc.)

EMPLOYER NAME:
Supervisor Name, Title, Daytime Phone:
Salary (Start-Final):
Employment Period (MO/YR):
Describe Major Duties, Responsibilities, Accomplishments:
May we contact?
Employer's Address:
Employer's Telephone #
Job Title
Reason for Leaving

EMPLOYER NAME:
Supervisor Name, Title, Daytime Phone:
Salary (Start-Final):
Employment Period (MO/YR):
Describe Major Duties, Responsibilities, Accomplishments:
May we contact?
Employer's Address:
Employer's Telephone #
Job Title
Reason for Leaving

EMPLOYER NAME:
Supervisor Name, Title, Daytime Phone:
Salary (Start-Final):
Employment Period (MO/YR):
Describe Major Duties, Responsibilities, Accomplishments:
May we contact?
Employer's Address:
Employer's Telephone #
Job Title
Reason for Leaving

I hereby authorize and request any and all of my former employers, educational institutions, and any other person, firm or corporation to furnish any and all information concerning my personal, education and/or employment background, and I hereby release each such employer, educational institution or other person, firm or corporation from any and all liability by reason of furnishing the requested information. All information I have provided in this application is true.

I understand that if employed: 1) any misrepresentation or omission of facts requested in this application is cause for dismissal; and 2) my employment is for no definite period and I may, regardless of the day of payment of my wages and salary, be terminated at any time without prior notice.

Applicant's Signature Date

* Required for online submissions (In leiu of signature).
I have agreed to submit this application by electronic means. I certify under penalty of perjury and false swearing that my answers are correct and complete to the best of my knowledge. I understand that this has the same legal effect and can be enforced in the same way as a written signature.

Enter security text (all numbers):


Pathways, Inc. | Search Site | pathwaysforyou.org