Employment Application Employment Application Step 1 of 8 0% Are you currently 18 years of age or older?* Yes No Thank you for your interest. The Arc of Dutchess requires all job applicants to be at least 18 years of age. Please select your highest level of education* High School Diploma / GED Associates Degree Bachelors Degree Masters Degree or Higher Position Desired*Select PositionDirect Support Professional ResidentialDirect Support Professional Day HabNursingManagementAdministrative/ClericalMaintenanceOtherPlease specify position:*Date* Date Format: MM slash DD slash YYYY PERSONALName* First Last Home Phone Number*Cell Phone Number*Email Address* Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code If hired, can you furnish proof that you are eligible to work in the United States?* No Yes Have you ever been employed by The Arc of Dutchess?* No Yes If so, when?*Have you ever applied to The Arc of Dutchess for a job?* No Yes Are you available to work:* Full Time Part Time Per Diem Which do you prefer?* 1st Shift 2nd Shift 3rd Shift Can you work weekends?* No Yes U.S. Military Service?* No Yes Branch or UnitHighest RankDo you have a valid Driver's License?* No Yes Please Note: If you should be called in for an interview, you will be required to bring your Driver's License.Has your license ever been suspended or revoked?* No Yes If yes, please explain:*How were you referred to The Arc of Dutchess? EDUCATIONALL APPLICANTS MUST PROVIDE THEIR ORIGINAL COLLEGE DEGREE OR TRANSCRIPT IF OFFERED EMPLOYMENTHigh School and all Vocational Schools*Type of SchoolName and Address of SchoolGraduated? (Yes/No)Type of Degree, Diploma or Certificate & Major/Minor Fields of Study All Colleges or Universities*Type of SchoolName and Address of SchoolGraduated? (Yes/No)Type of Degree, Diploma or Certificate & Major/Minor Fields of Study State Professional Licenses Held and Where RegisteredState Professional LicenseWhere Registered ACTIVITIESList relevant education, training or volunteer experience with individuals with developmental disabilities. REFERENCEProduct NameLIST THREE PERSONAL REFERENCES WHO ARE NOT RELATIVES*NameAddress (Street, City, State, And Zip Code)Phone NumberOccupation EXPERIENCEList employment in order from last to first. All sections must be completed even if resume is submitted.May we contact your present employer?* No Yes Employer*Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Date Started* Date Format: MM slash DD slash YYYY Date Ended* Date Format: MM slash DD slash YYYY Title*Supervisor*Reason for Leaving*Duties PerformedAdd more work experience?* No Yes Employer*Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Date Started* Date Format: MM slash DD slash YYYY Date Ended* Date Format: MM slash DD slash YYYY Title*Supervisor*Reason for Leaving*Duties PerformedAdd more work experience?* No Yes Employer*Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Date Started* Date Format: MM slash DD slash YYYY Date Ended* Date Format: MM slash DD slash YYYY Title*Supervisor*Reason for Leaving*Duties Performed BACKGROUND CHECKS Everyone with the potential to have unsupervised or unrestricted physical contact with people receiving services under OPWDD and/or OMH must have acceptable background checks completed on them prior to them beginning unsupervised work. Please complete the information below: Have you ever been convicted of or pled guilty to a felony, misdemeanor, violation, or other crime (other than a traffic violation)?** No Yes If yes, please provide details.**A conviction is not 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 or are you currently the subject of an indicated child abuse or maltreatment report on file with the New York Statewide Central Register of Child Abuse and Maltreatment (i.e., NYS Child Abuse Hotline)?* No Yes If yes, please provide details.*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?* No Yes If yes, please provide details.*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 any other state?* No Yes If yes, please provide details.* Please attach your ResumeAccepted file types: doc, docx, pdf. ALL QUALIFIED APPLICANTS ARE CONSIDERED FOR POSITIONS WITHOUT REGARD TO AGE, RACE, CREED, COLOR, NATIONAL ORIGIN, SEXUAL ORIENTATION, GENDER IDENTIFICATION AND EXPRESSION, MILITARY STATUS, SEX (EXCEPT WHERE A BONA-FIDE OCCUPATIONAL QUALIFICATION EXISTS), DISABILITY, PREDISPOSING GENETIC CHARACTERISTICS, MARITAL STATUS, OR DOMESTIC VIOLENCE VICTIM STATUS. AGREEMENT I certify that answers given herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision, 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 association. In signing this form, I certify that I understand all of the questions and statements in this application. Type your Full Name*Date* Date Format: MM slash DD slash YYYY