Preview Admin Employee Application Form

ADMINISTRATIVE

EMPLOYEE APPLICATION FORM

1. APPLICANT INFORMATION

Name: _____________________________________ _____________________________ ____________

(Last) (First) (Middle Initial)

ADDRESS: ______________________________________________________________________________

(Number) (Street) (Borough) (Zip Code)

SOCIAL SECURITY #:

___________ - _______ - ___________

ARE YOU ELIGIBLE FOR EMPLOYMENT IN THE U.S.?

Yes No

WHAT POSITION ARE YOU SEEKING?

____PHYSICAL THERAPIST___________

HOW SOON ARE YOU AVAILABLE TO WORK?

_Immediately__/ ___________/ __________

SALARY PREFERRED:

$ Per UFT Contract____

BOROUGHS PREFERRED:

_____________________________________________

SOURCE OF REFERENCE: Newspaper

Posting Other CIVIL SERVICE LIST______

HOME PHONE #: ( ) __________ - ____________

WORK PHONE #: ( ) __________ - ____________

HAVE YOU EVER BEEN CONVICTED OF A CRIME OR ARE ANY CRIMINAL CHARGES PENDING FOR

ANY OFFENSE (NOT INCLUDING TRAFFIC VIOLATIONS)?

Yes No If Yes, please explain: ____________________________________________

________________________________________________________________________________________

FAILURE TO ANSWER ALL QUESTIONS REGARDING CONVICTIONS AND/OR PENDING CRIMINAL

CHARGES COULD LEAD TO AUTOMATIC DISMISSAL. CONVICTIONS AND PENDING CRIMINAL

CHARGES DO NOT NECESSARILY CONSTITUTE A BAR TO EMPLOYMENT.

2. VETERANS STATUS (To Be Filled Out By Veterans Only)

Date of Discharge ______/ ______/ ______ Type of Discharge ______________________________

A DISHONORABLE DISCHARGE IS NOT AN ABSOLUTE BAR TO EMPLOYMENT AND OTHER FACTORS

WILL BE CONSIDERED BEFORE A FINAL DECISION IS MADE.

3. PRIOR CITY/STATE SERVICE

HAVE YOU EVER BEEN EMPLOYED BY THE CITY OR STATE OF NEW YORK?

Yes No If Yes, complete the following:

Department: __Department of Education_________ Title: ______________________________________

Status: Pv. Perm. Non-Comp. Date of Separation: ______/ ______/ ______

Reason For Separation: _____N/A____________________________________________________________

If you are retired, are you presently receiving a pension from any City or State retirement system:

Yes No

If yes, indicate Pension System and Agency: ____________________________________________________

PD 20/R. 1/11 (Please Complete Reverse Side)

Appl. Date: ____________________

Position Title: ____________________

Civil Service List #: _______________

Provisional ____________________

Transfer ____________________

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