The House of Good Shepherd Online Employment Application

PERSONAL INFORMATION
Name: Street Address: City: State: Zip:
Phone No: ( ) Email: Position:
How did you learn about The House of Good Shepherd (HGS)? If Other:
If you were referred to HGS by one of our employees, please list his/her name here:
Have you ever applied for a position with us? Yes No, If "yes," when and for what position?
Have you ever employed by us? Yes No, If "yes," when and in what program?
Some positions involve working evening and weekend hours, can you fill such scheduling requirements? Yes No Not Applicable
Do you desire: Full time? Part time? Summer?
If applying for the summer, indicate the dates during which you will be available from: to:
Are you over the age of 18? Yes No
Do you have the legal right to live and work in the United States? Yes No
Have you ever been convicted of or plead guilty to a crime? (A conviction will not automatically disqualify you from being considered as a candidate for employment.) Yes No
If "yes," please explain:
Do you have a valid driver's license? Yes No
Driver's License Number: Driver's License Expiration Date: Driver's License State:
Do you have any reason to believe your name may be listed within the New York State Central Register for the Abuse and Maltreatment of Children?
Yes No, If "yes," please explain:
 

EDUCATION
Type of School
Name and Address of School
Major
No. of Years Attended
Graduated?
Date of Graduation
High School
G.E.D.

Yes
No		  
Trade of Business School

Yes
No
College or University

Yes
No
Graduate School

Yes
No
Other formal training applicable to work at The House of the Good Shepherd:
Please list any hobbies or activities in which you are proficient that you might teach our children:
Are you certified in First Aid? Yes No Are you certified in C.P.R.? Yes No
Are you certified in Life Saving? Yes No Are you certified in W.S.I.? Yes No
 

PROFESSIONAL REFERENCES
Please list three (3) professional references.
Name
Address
Telephone
 

EMPLOYMENT HISTORY

List current or most recent employer first, including U.S. Military Service.
If any employment was under a different name, indicate name:
 
Employer 1: Address: Telephone:
Position Held: Dates of Employment: From: To: Full-Time Part-Time
Number of Hours: Ending Salary $: Supervisor Name:
Duties: Reason for Leaving:
 
Employer 2: Address: Telephone:
Position Held: Dates of Employment: From: To: Full-Time Part-Time
Number of Hours: Ending Salary $: Supervisor Name:
Duties: Reason for Leaving:
 
Employer 3: Address: Telephone:
Position Held: Dates of Employment: From: To: Full-Time Part-Time
Number of Hours: Ending Salary $: Supervisor Name:
Duties: Reason for Leaving:
 
Employer 4: Address: Telephone:
Position Held: Dates of Employment: From: To: Full-Time Part-Time
Number of Hours: Ending Salary $: Supervisor Name:
Duties: Reason for Leaving:
 
May we contact your present employer? Yes No
May we contact your previous employers? Yes No
If you answered "no," indicate which you do not want us to contact and why:
 

APPLICANT ACKNOWLEDGEMENT

*PLEASE READ CAREFULLY BEFORE SIGNING*

I hereby certify that all of the information provided by me in this application (or any accompanying documents) is correct, accurate and complete to the best of my knowledge. I understand that the falsification, misrepresentation or omission of any facts in said documents may be cause for denial of employment or immediate termination of employment regardless of the timing or circumstances of discovery.

I understand that submission of an application does not guarantee employment. I further understand that if employed, my employment with The House of the Good Shepherd (hereinafter referred to as "HGS") is at-will and for no specified duration and may be terminated by either HGS or myself at any time, with or without cause or notice. I understand that none of the documents, policies, procedures, actions or statements of HGS representatives used during the employment process alter the at-will nature of my employment in any way or is deemed a contract of employment, real or implied.

If employment with HGS is obtained under this application, I agree to conform to the rules, regulations, policies and procedures of HGS, which I understand are subject to change from time to time by the Agency, at all times and understand that such compliance is a condition of employment. I understand that due to the nature of HGS business, attendance and punctuality are considered essential requirements of every employee of HGS and that poor attendance or tardiness will result in disciplinary action.

I understand that placement into any position offered is conditioned upon the Agency's receipt of a satisfactory background investigation. The investigation will include verification of employment history and education, and, where appropriate, may also include but not be limited to investigation of criminal record, driving record, status with the State Central Register for the Abuse and Maltreatment of Children and professional references. I understand that any offer of employment is contingent upon my passing a drug test conducted at a site designated by HGS, and that failure to submit to or pass the drug test will rescind the offer of employment in accordance with the Agency's Drug Free Workplace Policy. Additionally, I understand that placement will be conditioned upon satisfactory completion of a job-related physical examination.

I hereby authorize any and all schools, former employers, references, courts and any others who have information about me to provide such information to HGS and/or any of its representatives, and I release all parties involved from any and all liability for any and all damage that may result from providing such information. I understand that this application is considered current for one year. If I wish to be considered for employment after this period I must fill out and submit a new application.

It is the policy of The House of the Good Shepherd to hire, place, transfer and promote employees without regard to race, color, sex, national origin, religion, age, veteran status, non-job-related condition, disability, sexual orientation or any other legally protected status.
Print your full name into this box if you acknowledge that you have read, understand and agree with the above statement: