HTML Preview Admin Employee Application Form page number 1.
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)
FOR OFFICE USE
Appl. Date: ____________________
Position Title: ____________________
Civil Service List #: _______________
Provisional ____________________
Transfer ____________________
Reinstatement ____________________
X
X