Employment Application
Welcome to the State University of New York Polytechnic Institute (SUNY Poly). We appreciate your interest in our organization. We
encourage you to provide all the information requested on this application. Thank you.
We are an equal opportunity/affirmative action employer. Personnel are chosen on the basis of ability. SUNY Poly will not discriminate in its
employment practices due to an applicant’s race, creed, religion, color, citizenship, national origin, sex, age, sexual orientation, predisposing
genetic characteristics, gender identification, genetic information, familial status, marital status, pregnancy, status as a domestic violence victim,
criminal conviction, disability, military status, disabled veteran, recently separated veteran, Armed Forces Service Medal veteran, active duty or
wartime campaign badge veteran, or other characteristic as protected by law, in accordance with federal and state law.
The University’s policy is in accordance with federal and state laws and regulations prohibiting discrimination and harassment. These laws
include the Americans with Disabilities Act (ADA), Section 504 of the Rehabilitation Act of 1973, Title IX of the Education Amendments of 1972,
Title VII of the Civil Rights Act of 1964 as Amended by the Equal Employment Opportunity Act of 1972 and the New York State Human Rights
Law. These laws prohibit discrimination and harassment, including sexual harassment and sexual violence.
Inquiries regarding the application of Title IX and other laws, regulations and policies prohibiting discrimination may be directed to the Title IX
Coordinator TitleIX@sunypoly.edu at SUNY Polytechnic Institute. Inquiries may also be directed to the United States Department of Education’s
Office for Civil Rights, 32 Old Slip 26th Floor, New York, NY 10005-2500; Tel. (646) 428-3800; Email OCR.NewYork@ed.gov.
Invitation for self-identification - individuals with disabilities and veterans who wish to benefit under the affirmative action program are invited
to identify themselves. These forms are available at the location listed below. This information is strictly voluntary and will be kept confidential.
Refusal to provide it will not subject the applicant or employee to any adverse treatment, and it will be used only in accordance with government
regulations.
Position:
Posting Reference Number:
Campus Location:
Applicant Information
Last Name:
First Name:
Middle Initial:
Street Address:
City:
State:
Zip/Postal Code:
Home Telephone Number
( )
Alternate Telephone Number
( )
Salary Requirements:
$
Type of Employment Desired:
Full-time Part-time Temporary
Email Address:
Are you CURRENTLY, or have you been, employed at SUNY Poly, SUNY CNSE, SUNYIT or any other public employer in the State of
New York?
YES NO If yes, list agency and dates. Retired? YES NO
As a result of prior employment with a public employer in the State of New York are you receiving a pension from a retirement system?
NOTE: NYS Law imposes strict limitations on those retired or intending to retire and draw a pension from a NYS public employment system.
YES NO If yes, list agency and dates.
Have you been employed by the Research Foundation for SUNY?
YES NO If yes, list location and dates.
Will you now or in the future require sponsorship for employment visa (e.g. H1-B)? Proof of identity and either U.S. citizenship or
Employment authorization are required prior to employment.
YES NO If yes, please provide dates and details.
Are you under 18 years old?
YES NO If yes, you are required to provide appropriate work authorization papers.
Have you ever served in any branch of the United States Armed Forces?
YES NO If yes, type of discharge.
Do you have any relatives currently working for SUNY Polytechnic Institute or Research Foundation for SUNY? An answer of “yes
doesn’t automatically bar you from employment. Each case is considered and evaluated in relation to the duties and responsibilities of
position for which you are applying.
YES NO If yes, please provide name(s) and relationship.
Applicants are not required to disclose information pertaining to sealed conviction records, youthful offender adjudications, or criminal charges
that have been resolved in favor of the applicant (e.g. dismissal). Applicants for Employment in the Cities of New York City, NY,
Buffalo,
NY, or Rochester, NY should not complete the question related to criminal history below. Applicants for employment in those citi
es
will be required to complete a disclosure document of criminal history after the completion of an initial review.
A conviction or pending criminal charges are not an automatic bar from employment. Each case is considered and evaluated on
its individual
merits in relation to the duties and responsibilities of the position for which you are applying.
Failure to disclose a prior conviction may result in
denial of employment or subsequent termination of employment based on falsification of the employment application.
Have you ever been convicted of, or pled guilty or no contest to, a crime (felony or misdemeanor)? Please be sure to include Motor
Vehicle Traffic misdemeanors.
YES NO If yes, Please provide date(s) of conviction(s)/arrest(s) and offense(s):
Do you have an arrest or criminal charges currently pending against you?
YES NO If yes, Please provide specifics:
Do you have a valid New York State Driver’s license? Certain positions may require a valid license for operation of a motor vehicle
for employment-related purposes
YES NO
Have you taken a qualifying Civil Service Examination?
YES NO If yes, please list title of examination(s) and score(s)
Have you ever, or are you currently involved in any form of disciplinary or investigative process before any state licensing body or
any accrediting body?
YES NO If yes, provide details.
My resume with employment history Is Isn’t attached.
If your resume is not attached, you must provide your education and employment history, beginning with your present or last employer, on
the next page of this application or on additional sheets.
My references Are Arent attached.
If not attached, provide name, title, address, and telephone number of three work-related (preferably supervisory) references.
I hereby authorize investigation of all statements contained in this application and attached data as provided. I certify that such statements are
true and understand that misrepresentation or omission of facts called for in this form may be cause for termination of employment without
notice. I hereby also agree to hold SUNY Poly harmless in divulging the information contained in this application form as well as any personnel
records developed as a result of employment with SUNY Poly. A pre-employment examination by a SUNY designated physician may be required
if physical condition is a job-related qualification. For some positions, a pre-employment physical examination is required by law.
I also agree, if employed, to abide by all policies and procedures of SUNY Poly. SUNY Poly is a drug-free workplace.
____________________________________________________________________________________
Applicant’s Signature Date
Please return this application to: Assistant Director of Recruitment and Employee Relations
SUNY Polytechnic Institute
257 Fuller Rd.
Albany, NY 12203
SUNYPolyHR@sunypoly.com
Education
High School: (Name and Location) Course: Graduate:
Yes No
___________________________________________________________________________________________________
Business or Trade Schools: (Name and Location) Course: Graduate:
Yes No
___________________________________________________________________________________________________
Special Skills or Training: Licenses Held:
___________________________________________________________________________________________________
College: (Name and Location)
___________________________________________________________________________________________________
Degree: Major: Graduate:
Yes No
___________________________________________________________________________________________________
Graduate School: (Name and Location)
___________________________________________________________________________________________________
Degree Earned Major:
___________________________________________________________________________________________________
Employment
List your employment record starting with your present or last employer first. Show all employment and periods of unemployment if more than one
month. Include military service. Use additional sheets if necessary.
Date From: Month/Year Employer’s Name Department, Division, or Section
___________________________________________________________________________________________________
To: Month/Year Address Supervisor Telephone Number
___________________________________________________________________________________________________
Title:
___________________________________________________________________________________________________
Briefly describe the duties of your position:
___________________________________________________________________________________________________
Reason for leaving: May we contact this employer? Yes No
___________________________________________________________________________________________________
Date From: Month/Year Employer’s Name Department, Division, or Section
___________________________________________________________________________________________________
To: Month/Year Address Supervisor Telephone Number
___________________________________________________________________________________________________
Title:
___________________________________________________________________________________________________
Briefly describe the duties of your position:
___________________________________________________________________________________________________
Reason for leaving: May we contact this employer? Yes No
___________________________________________________________________________________________________
Date From: Month/Year Employer’s Name Department, Division, or Section
___________________________________________________________________________________________________
To: Month/Year Address Supervisor Telephone Number
___________________________________________________________________________________________________
Title:
___________________________________________________________________________________________________
Briefly describe the duties of your position:
___________________________________________________________________________________________________
Reason for leaving: May we contact this employer? Yes No
___________________________________________________________________________________________________
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