Fillable ADULT STERILE PROCESSING TECHNICIAN Albany-Schoharie-Schenectady-Saratoga BOCES (Capital Region BOCES)

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ADULT STERILE PROCESSING TECHNICIAN Albany-Schoharie-Schenectady-Saratoga BOCES (Capital Region BOCES)

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  • 50 check-boxes
  • 68 other fields

Country of origin: US
File type: PDF

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Street City State Zip
Date of Birth: Age: Sex: [ ] Male [ ] Female Social Security #
Cell Phone: ( ) Home Telephone: ( ) E-Mail:
PERSONAL STATUS: (Check one) [ ] Veteran [ ] U.S. Citizen or [ ] Alien Registration ID#
ETHNIC GROUPING: (Check one)
[ ] Black or African American [ ] Hispanic/Latino [ ] Asian [ ] American Indian/Alaska Native
[ ] White [ ] Native Hawaiian or Pacific Islander [ ] 2 or more races [ ] Unknown
Are you a non-native English speaker? [ ] Yes [ ] No
Are you limited in your ability to speak or understand English? [ ] Yes [ ] No
FAMILY STATUS: (Check one) [ ] Single [ ] Married [ ] Widowed [ ] Separated [ ] Divorced
Do you have children? Yes [ ] No [ ] How many?
Write in each box, the number of your own children by age group who are living with you.
0-2
3-5 6-12
13-16 17+
EDUCATION/TRAINING: Circle highest grade of school completed:
K 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17+
[ ] High School (transcripts required) - Year [ ] GED (copy required) - Year
[ ] Post Secondary/College(transcripts required) - Year(s) Degree(s) Received ______
Any other license or certificate?
How did you learn about this program?
[ ] Referral Source: Telephone:
Are you presently employed? [ ] No Are you receiving unemployment? [ ] Yes [ ] No
[ ] Yes Employer:
Job Title:
Do you receive any of the following Public Assistance? (Check all that apply):
[ ] Aid for Dependent Children (AFDC) [ ] Rental Assistance from the Department of Social Services
[ ] Supplemental Security Income (SSI) [ ] Women, Infants and Children (WIC)
[ ] Home Relief (HR) [ ] Medicaid [ ] Food Stamps
Do you have a disability or medical condition that may affect or limit your ability to work or attend school?
[ ] Yes [ ] No Please describe:
NOTE: Any previous criminal felony or misdemeanor conviction may prevent you from obtaining
Licensure
Please print or type all information. Applying for [ Fulltime _______ [ art-time__
mo/yr mo/yr
Name:
Last First MI
Address:
______ ] P ]
ADULT STERILE PROCESSING TECHNICIAN
Albany-Schoharie-Schenectady-Saratoga BOCES
PLEASE NOTE: All information on this form is CONFIDENTIAL. Only the data will be used for statistical
purposes.
SIGNATURE: DATE:
ADULT STERILE PROCESSING TECHNICIAN
Albany-Schoharie-Schenectady-Saratoga BOCES
PRELIMINARY AGREEMENT
Please write a statement explaining what you hope to gain by coming to BOCES at this time:
Release of Information:
I understand that the information on this application will be kept private and confidential. I allow Albany-
Schoharie-Schenectady-Saratoga BOCES to submit this application to appropriate funding agencies to
ascertain my eligibility for financial assistance to attend BOCES Adult Education Programs. I allow BOCES to
use this release of information to seek and provide information to relevant agencies within and outside BOCES
and to employers regarding my attendance and participation as based on funding assistance requirements. I
understand that information regarding current status of physical, medical and psychological conditions will be
sought and secured by a separate release outlining the need and use of information requested.
Signature: Date:
Staff Signature: Date:
CONSENT FORM
[ ] I give consent (agree)
[ ] I
do not give consent (do not agree)
t
o allow the release of information (data from this application, test data, notes, correspondence and other
documents) in written or verbal to personnel from the referring agency and/or other relevant funding agencies
and appropriate organizations.
Signature: Date:
Witness Signature/Title: Date:
If you need the assistance of an interpreter, need material translated into any language other than English, please call Ottavio Lo Piccolo at (518) 862-4703 and leave a voice message. Thank you.
Si usted necesita asistencia de un interprete, o necesita traducion en espanol, y otros idiomas, por favor llame a Ottavio Lo Piccolo a este tel. (518) 862-4703, y deje un mensaje de voz. Gracias
The Capital Region BOCES does not discriminate on the basis of race, color, national origin, sex, disability, or age in its programs, activities, employment, and admissions; and provides equal access to the Boy Scouts
and other designated youth groups. The following person has been designated to handle inquiries regarding the non-discrimination policies: Robert Zordan, compliance officer/coordinator, at
robert.zordan@neric.org, (518) 862-4910 or 900 Watervliet-Shaker Road, Albany, NY 12205. Inquiries concerning the application of the Capital Region BOCES non-discrimination policies may also be
referred to the U.S. Department of Education, Office for Civil Rights (OCR), 32 Old Slip, 26th Floor, New York, NY 10005, telephone (646) 428-3800 (voice) or (800) 877-8339 (TTY).
-2-
1. Employer: From: To:
Address: Title:
Job Responsibilities:
Reason for Leaving:
2. Employer: From: To:
Address: Title:
Job Responsibilities:
Reason for Leaving:
3. Employer: From: To:
Address: Title:
Job Responsibilities:
:
r Leaving:
Please list all employment in the last five years (list most recent experience first).
Reason for Leaving
4. Employer: From: To:
Address:
Title:
Job Responsibilities:
Reason fo
SIGNATURE: DATE:
-3-
REVISED: January 2018, made accessible - bb
ADULT STERILE PROCESSING TECHNICIAN
Albany-Schoharie-Schenectady-Saratoga BOCES
EMPLOYMENT HISTORY
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ADULT STERILE PROCESSING TECHNICIAN Albany-Schoharie-Schenectady-Saratoga BOCES (Capital Region BOCES)

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Completed 16 September 2021

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