Hayes Application Form – Fill Out and Use This PDF

PLEASE฀NOTE:฀This฀application฀must฀be฀completely฀fi฀lled฀in.฀All฀requested฀information฀must฀be฀provided฀in฀order฀for฀your฀application฀to฀be฀considered.

POSITION฀APPLIED฀FOR:

SECTION฀A฀–฀Personal฀Information฀(PLEASE฀PRINT)

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฀฀฀฀฀฀Last฀

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฀฀First฀

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Name:฀

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฀฀฀฀Social฀Security฀#:

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฀฀฀฀฀฀No.฀&฀Street฀or฀RFD฀

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City฀

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State฀

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Zip฀code

Address:

List฀county฀and฀state฀of฀residences฀over฀the฀last฀10฀years฀if฀different฀than฀above.

Please฀answer฀the฀following฀questions฀by฀marking฀the฀appropriate฀box.฀฀If฀you฀answer฀YES฀to฀questions฀3,฀4,฀7,฀8฀and/or฀9฀give฀details฀on฀an฀attached฀sheet.

1.฀Do฀you฀have: ฀฀❏฀Relatives ฀฀฀❏฀Friends฀฀฀฀employed฀at฀this฀facility?฀ ❏฀Yes฀฀ ❏฀No฀฀฀฀Department:

2.฀Are฀you฀a฀citizen฀of฀the฀United฀States?฀ ❏ Yes฀฀ ❏ No฀฀฀฀฀฀฀If฀no,฀do฀you฀have฀the฀legal฀right฀to฀accept฀employment฀in฀the฀U.S.?฀ ❏ Yes฀฀ ❏ No

3.฀Except฀for฀adjudications฀as฀a฀youthful฀offender,฀wayward฀minor฀or฀juvenile฀delinquent,฀have฀you฀ever฀been฀found฀guilty฀of฀ANY฀misdemeanor, felony,฀offense฀or฀forfeited฀bail฀in฀any฀court?฀ ❏ Yes฀฀ ❏ No฀฀If฀yes,฀give฀details฀on฀attached฀sheet.฀A฀conviction฀is฀not฀an฀automatic฀bar฀to employment.฀Each฀case฀is฀considered฀on฀individual฀merits. Are฀there฀any฀criminal฀charges฀currently฀pending฀against฀you? ❏Yes ❏No

4.฀Did฀you฀serve฀on฀active฀duty฀with฀the฀armed฀forces฀of฀the฀United฀States?฀ ฀฀❏ Yes฀฀ ❏ No฀฀฀฀If฀yes,฀give฀dates:

฀Are฀you฀certifi฀ed฀by฀the฀Veteran's฀Administration฀as฀a฀disabled฀veteran?฀฀ ฀฀฀❏ Yes฀฀ ❏ No

5.฀Have฀you฀ever฀worked฀for฀NY฀State?฀฀ ❏ Yes฀฀ ❏ No

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Department:฀

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Dates฀(From-to):฀

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฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀Position฀Title:฀

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฀฀฀฀฀฀฀฀฀฀฀฀Status*:

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*฀(P)฀Permanent฀

(CP)฀Contingent฀Permanent฀

(T)฀Temporary฀

(PR)฀Provisional

฀Were/are฀you฀a฀member฀of฀the฀NYS฀Retirement฀System?฀ ❏ Yes฀฀ ❏ No฀฀฀฀฀If฀yes,฀give฀Retirement฀System฀#:

6.฀List฀other฀names฀under฀which฀your฀work฀records฀might฀appear

7.฀Have฀you฀ever฀been฀discharged฀from฀any฀employment฀for฀reasons฀other฀than฀lack฀of฀work฀or฀funds,฀or฀have฀you฀ever฀resigned฀from฀employ- ment฀in฀lieu฀of฀discharge?฀฀฀ ❏ Yes฀฀ ❏ No฀฀If฀yes,฀give฀details฀on฀attached฀sheet.

8.฀Have฀you฀ever฀been฀involved฀in฀a฀patient฀abuse,฀mistreatment฀and/or฀neglect฀investigation฀by฀any฀facility฀or฀state฀agency฀(e.g.฀Dept฀of Health,฀Child฀Abuse฀Registry,฀Dept.฀of฀Social฀Services)?฀฀฀ ❏ Yes฀฀ ❏ No฀฀If฀yes,฀give฀details฀on฀attached฀sheet.

9.฀Has฀your฀ability฀to฀be฀able฀to฀bill฀medicaid฀or฀medicare฀or฀other฀third฀party฀payors฀ever฀been฀revoked,฀suspended,฀curtailed฀or฀limited฀in฀any fashion?฀฀ ❏ Yes฀฀ ❏ No฀฀If฀yes,฀give฀details฀on฀attached฀sheet.

SECTION฀B฀–฀Education฀&฀Training (Attach฀additional฀sheets฀if฀necessary฀to฀give฀your฀complete฀background)

Circle฀highest฀grade฀completed:฀฀฀฀฀1฀฀฀฀฀2฀฀฀฀฀3฀฀฀฀฀4฀฀฀฀฀5฀฀฀฀฀6฀฀฀฀฀7฀฀฀฀฀8฀฀฀฀฀9฀฀฀฀฀10฀฀฀฀฀11฀฀฀฀฀12฀฀฀฀฀฀฀฀Did฀you฀graduate?฀฀❏ Yes฀฀ ❏ No

If฀you฀have฀a฀NYS฀High฀School฀Equivalency฀Diploma฀(GED)฀please฀provide:฀

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Number-฀฀

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Date฀Issued-

LICENSES฀- If฀you฀possess฀a฀license,฀certifi฀cate฀or฀other฀authorization฀to฀practice฀a฀trade฀or฀profession,฀complete฀the฀following฀section฀and฀attach฀copy.

SECTION฀C฀–฀Employment฀History (Begin฀with฀most฀recent฀employment฀and฀be฀sure฀to฀include฀any฀employment฀with฀NYS.฀List฀all฀previous

฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀employers.฀Add฀additional฀sheets฀if฀necessary.฀A฀resume฀may฀be฀substituted฀for฀this฀section฀if฀it฀provides฀essentially฀the฀same฀information.

SECTION฀D฀–฀References

May฀we฀contact฀your฀current฀employer(s)?฀ ❏฀Yes฀฀ ❏฀No

Provide฀names,฀addresses฀and฀telephone฀numbers฀of฀three฀references฀who฀are฀not฀related฀to฀you.

Note:฀฀Exposure฀to฀potentially฀hazardous฀substances฀may฀be฀involved฀with฀some฀positions.฀Candidates฀who฀accept฀appointment฀positions฀may be฀required฀to฀wear฀personal฀protective฀equipment,฀undergo฀pre-employment฀and฀periodic฀health฀evaluations฀and/or฀specifi฀c฀immunizations.

I฀hereby฀affi฀rm฀that฀this฀application฀contains฀no฀misrepresentations฀or฀falsifi฀cations฀and฀that฀this฀information฀given฀by฀me฀is฀true฀and฀complete

to฀the฀best฀of฀my฀knowledge฀and฀belief.฀I฀am฀aware฀that฀should฀investigation฀at฀any฀time฀disclose฀any฀misrepresentation฀or฀falsifi฀cation,฀my฀฀฀฀฀฀฀฀฀฀

application฀will฀be฀disapproved฀and฀my฀appointment฀may฀be฀rescinded.฀I฀am฀also฀aware฀that฀a฀false฀statement฀is฀punishable฀under฀law฀by฀fi฀ne฀or imprisonment฀or฀both.

Signature฀฀

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Date

Updated฀1/07