Fillable Application for Employment (New York State Education Department)

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Application for Employment (New York State Education Department)

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The New York State Education Department
OFFICE OF HUMAN RESOURCES MANAGEMENT
Application for Employment
PERSONAL HISTORY Position Applied For: Box #
Name (Last, First, MI)
Provide Any Other Names Used
Street Address
City
State
Zip Code
Home Phone
( )
Work Phone
( )
Cell Phone
( )
EMAIL ADDRESS
SOCIAL SECURITY NUMBER
(Last Four Digits Only)
XXX - XX -
No
ARE YOU OVER 18 YEARS OLD?
Yes No
NO SPONSORSHIP IS AVAILABLE FOR POSITIONS IN NYSED.
DO YOU HAVE A DRIVER’S LICENSE? STATE LICENSE #
Yes No
HOW DID YOU HEAR ABOUT
OUR VACANCY?
Facebook StateJobsNY SED Website Other
Yes
No
HAVE YOU EVER WORKED FOR THE STATE EDUCATION DEPARTMENT?
IF SO, DATES: From: To:
HAVE YOU EVER WORKED FOR ANOTHER NEW YORK STATE AGENCY? Yes No
IF SO, AGENCY:
From:
To:
Answer the following questions by checking either "Yes" or "No." If you answer “Yes” to any of the following questions,
provide details* in the space provided (attach additional sheets as necessary.) A “Yes” answer to any of these questions
does not represent an automatic bar to employment. E
ach application for employment is evaluated on its individual merits
and against the duties, responsibilities and qualifications of the position being filled. However, your failure to respond to
these questions may result in your removal from further consideration for employment.
Yes No 1. Have you ever been discharged or dismissed from any public or private employment for reasons
Yes
Yes
Yes
Yes
other than lack of work or lack of funds?
No 2. Have you ever resigned
from any position rather than face dismissal or disciplinary charges?
No 3. Have you ever failed probation at another state agency?
No 4. Have you ever been convicted of a crime (felony or misdemeanor)?**
No 5. Are any criminal charges currently pending agains
t you?
*DETAILS:
**
Y
o
u s
h
o
u
l
d answer “No” if one of the following conditions apply:
- Your conviction was sealed by a court, or
- The criminal action or proceeding was terminated in your favor, e.g. you were acquitted or dismissed, you
received an adjournment in contemplation of dismissal and the adjournment period has lapsed, or
- The procedure on the criminal offense resulted in a youthful offender adjudication or juvenile delinquency finding
which has been sealed/expunged pursuant to the Family Court Act, or
- After completing a treatment program, your plea to a felony or a misdemeanor was withdrawn and you were
resentenced to a violation which was sealed by the court, or the completion of the program resulted in a dismissal
of all charges by the court.
Failure to disclose a prior conviction that does not meet the above criteria may result in denial of employment or if
chosen for the position, subsequent termination based on falsification of the application for employment.
An Equal Opportunity Employer
New York State and Federal Law prohibit discrimination on the basis of race, creed, color, national origin, religion, age, sex, military, marital
status, familial status, domestic violence victim status, carrier status, disability, genetic predisposition, sexual orientation and criminal record.
ARE YOU LEGALLY AUTHORIZED
TO WORK IN THE UNITED STATES?
Yes
PROVIDE DETAILS HERE. ATTACH ADDITIONAL SHEETS IF NECESSARY.
New York State Education Department – Application for Employment Page 2 of 4
For the purposes of reviewing your employment application, do you have any relatives by blood or
marriage, or members of your household currently employed by the New York State Education
Department? If yes, please identify employee(s) and relationship.
Yes No
EDUCATION (Must be filled out completely. Resumes will not be accepted in lieu of completing this section. Applicants may
be required to provide proof of diploma and/or degrees claimed.)
Name of School and Location Attended
From
(mm/yyyy)
To
(mm/yyyy)
Credit
Hours
Completed
Did
You
Graduate?
Major
Subject
Degree
Received
High School
or
Equivalency
College,
University, or
Technical
School
Graduate
or
Professional
School
Other
Schools
or
Special
Courses
PROFESSIONAL LICENSES/CERTIFICATIONS
Professional Licenses/Certifications
Permanent
or
Provisional
Certificate
or
License #
Name of Issuing Agency or State
Effective
Date
(mm/dd/yyyy)
Expiration
Date
(mm/dd/yyyy)
(For some positions, professional licensure, registration, certification, or other authorization to practice
a trade or profession is required.)
PROVIDE NAME AND RELATIONSHIP
New York State Education Department – Application for Employment
Page 3 of 4
WORK EXPERIENCE (Must be filled out completely. Resumes will not be accepted in lieu of completing this section. If extra
space is needed, please attach additional sheets.)
Name, Address & Telephone Number of Employer
From
(mm/yyyy)
To
(mm/yyyy)
Super
visor:
Title & Duties
Name, Address & Telephone Number of Employer
From
(mm/yyyy)
To
(mm/yyyy)
Super
visor:
Title & Duties
Name, Address & Telephone Number of Employer
From
(mm/yyyy)
To
(mm/yyyy)
Super
visor:
Title & Duties
REFERENCES
Name
Telephone Number
Type of Reference (i.e. Professional,
Personal, Supervisor, etc.)
( ) -
( ) -
( ) -
DUAL EMPLOYMENT
If offered a position with the State Education Department, will you maintain employment elsewhere? If yes,
please identify other position(s), including self-employment.
Name of Organization:
Address:
Title of Position:
Dates: From To
New York State Education Department – Application for Employment Page 4 of 4
AFFIRMATION
I affirm that all statements made on this form, including any accompanying papers, are true,
accurate and complete to the best of my knowledge under penalty of perjury. I further authorize
investigation of said statements. Verification of information may be required prior to appointment. I
understand that any false, incomplete or misleading statements made on this form or accompanying
papers may nullify my appointment or lead to my termination.
Print Name
Signature Date
AUTHORIZATION
I hereby authorize the New York State Education Department to investigate references from my
previous or current employers. I further authorize any former employer, military records
center, and any former school, college, university, or organization to provide the New York State
Education Department any and all information including, but not limited to, information as to my
character, work habits, work performance and education, qualifications, and fitness for the
position, thereby releasing and discharging said institutions from any claims, liabilities or
damages whatsoever incurred in furnishing such information.
Print Name
Signature Date
PERSONAL PRIVACY PROTECTION NOTIFICATION
The information you are providing on this application is being requested pursuant to New York State Public
Authorities Law and Civil Service Law for the purposes of determining eligibility for employment,
administering employee benefit programs and administering other authorized employment programs pursuant
to local, state or federal law. Failure to provide the requested information may, in the sole discretion of the
New York State Education Department, prevent your initial hiring or result in the termination of your
employment. If appointed, this employment application will be filed in your personal history folder
maintained by the Office of Human Resources Management, New York State Education Department, 89
Washington Avenue, Albany, New York 12234.
PD-40 (10/18)
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Completed 15 August 2020

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