3
ARE YOU A CITIZEN OF THE UNITED STATES?
IF “NO,” DO YOU HAVE A LEGAL RIGHT TO WORK IN THE UNITED STATES?
YES NO
A) EXCEPT FOR ADJUDICATIONS AS YOUTHFUL OFFENDER, WAYWARD MINOR, OR JUVENILE
DELINQUENT, HAVE YOU EVER BEEN CONVICTED OF A MISDEMEANOR OR FELONY?
B) DO YOU HAVE ANY CRIMINAL CHARGES PENDING AGAINST YOU?
C) HAVE YOU EVER BEEN DISMISSED FROM ANY EMPLOYMENT?
D) HAVE YOU EVER RECEIVED A DISCHARGE FROM THE ARMED FORCES THAT WAS
OTHER THAN HONORABLE?
E) ARE YOU CURRENTLY IN VIOLATION OF A COURT ORDER IN ANY STATE
FOR CHILD OR SPOUSAL SUPPORT?
If you answer “yes” to any of these questions, provide details on page 4.
YES NO
I affirm that the statements made on this application (including any attached pages) are true.
[False statements made in this application are punishable under Penal Law (§210.45) and may result in your disqualification.]
SIGNATURE OF APPLICANT DATE
((#+#&"#)&(,'(!'"%) $$#&()"(,!$ #,&
Answer all questions by placing an X in the appropriate column.
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