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THE CITY UNIVERSITY OF NEW YORK EMPLOYMENT APPLICATION (City University of New York)

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Rev. 7/14/20 CUNY Employment Application Part 4 1
THE CITY UNIVERSITY OF NEW YORK EMPLOYMENT APPLICATION – PART FOUR
LICENSE OR PROFESSIONAL REGISTRATION VERIFICATION
LICENSES AND PROFESSIONAL REGISTRATIONS MAY BE REQUIRED FOR CERTAIN TITLES.
CA
NDIDATES FOR EMPLOYMENT WHO ARE REQUIRED TO HAVE A CURRENT LICENSE OR PROFESSIONAL
REGISTRATION MUST SUBMIT THIS FORM AT THE TIME OF HIRE, PRIOR TO ANY APPOINTMENT. COPIES OF LICENSE
OR REGISTRATION MAY BE REQUIRED.
EM
PLOYEES ARE RESPONSIBLE FOR MAINTAINING CURRENT LICENSE /PROFESSIONAL REGISTRATION AND MUST
UPDATE THEIR RECORDS IN THE OFFICE OF HUMAN RESOURCES.
La
st Name: __________________________ First Name: _________________________ Middle Initial: ________
Co
llege: __________________________________ Department: _______________________________________
Contract Title: ______________________________________ Full Time Part Time
Da
te: __________________________
Name of License/Registration: ____________________________________________________________________
Name of Issuing Agency: _________________________________________________________________________
License Number: __________________________ Date Issued: ________________ Exp. Date: ____________
Date Last Renewed: _______________________ Renewal #: _________________ Exp. Date: __________
Have you ever had this license, certificate or permit suspended or revoked? Yes No
If yes, provide details:
Name of License/Registration: ____________________________________________________________________
Name of Issuing Agency: _________________________________________________________________________
License Number: __________________________ Date Issued: ________________ Exp. Date: ____________
Date Last Renewed: _______________________ Renewal #: _________________ Exp. Date: ___________
Have you ever had this license, certificate or permit suspended or revoked? Yes No
If yes, provide details:
Rev. 7/14/20 CUNY Employment Application Part 4 2
I hereby certify that the information provided is accurate.
S
ignature: _________________________________________________ Date: ________________________
Office of Human Resources
N
ame: ____________________________________________________ Date: ________________________
S
ignature: _________________________________________________
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THE CITY UNIVERSITY OF NEW YORK EMPLOYMENT APPLICATION (City University of New York)

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Completed 2 February 2022

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