Employment Application

Employment Application

PART 1 - PRE-INTERVIEW
The Thomas Academy (TA) is an equal opportunity/affirmative action employer. NYS Law prohibits discrimination because of age, race, creed, color, national origin, sexual orientation, military status, sex, disability, predisposing genetic characteristics, marital status, domestic violence victim status, carrier status. gender identity or prior conviction records, or prior arrests, youthful offender adjudications, or sealed records unless based upon a bona ride occupational qualification or other exception.
Identifying Information
Please read all instructions carefully. All pages of this application must be completed, and the application signed. If you need additional space, please use the ADDITIONAL REMARKS section. Applicants may be required to complete additional components of the Employment Application as directed by the hiring agency. Part 2 of the Thomas Academy Application must be completed by Applicants after the interview process.
Name

First NameLast Name
SSN
Current Mailing/ Street Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
NYS EMPLID (if assigned)
Email
example@example.com
Permanent Street Address (if different from above)
Home Phone

Area CodePhone Number
Business Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number

List any other names by which you have been known (including nicknames)

	Nicknames
1
2
3

Application Information
1. All candidates must be eligible for employment the United States and maintain this eligibility throughout their employment with (TA). Employment is contingent upon the provision of proof of the right to accept employment in the United States.
Are you legally authorized to work in the United States?

YesNo
If under age 18, can you provide a work permit?

YesNo
Will you new, or in the future. require sponsorship for employment visa status (e.g. for an H-1B Visa)?

YesNo
POSITIONS MAY REQUIRE TRAVEL AND/OR OPERATION OF A MOTOR VEHICLE OR HEAVY EQUIPMENT

2. Certain positions may require extensive travel within a designated area of assignment: to otherwise travel in areas that may not be served by public transportation; to routinely operate a motor vehicle; and/or to routinely operate heavy equipment requiring a specialized license.

For positions requiring operation of a motor vehicle or heavy equipment. appointees must possess a driver license valid in NYS at the time of appointment and continuously thereafter.Candidates who do not possess a driver license valid in NYS must be able to demonstrate their capacity to meet the transportation needs of the job at the time of interview.
Do you currently have a valid driver license that allows you to operate a motor vehicle in New York State?

YesNo
please select your license class

CDLABCDEOther
Licensing State
License Number

For Commercial Driver License (COL) holders. Please list your endorsements or restrictions

	Endorsements / Restrictions
1.
2.
3.
4.

Have you ever had your driver license revoked or suspended?

YesNo
please explain
POSITIONS MAY REQUIRE PROFESSIONAL LICENSURE OR CERTIFICATION

3. For some positions, professional licensure, registration, certification, or other authorization to practice a trade or profession is required. Applicants claiming these credentials will be required to provide proof as a part of the screening process. If you are required to possess such credentials for the position you are applying for, please complete the following questions:
Name of Trade or Professional License/Certificate
License No
Issued By
Issued By
Expiration Date
Registration Date
Registration Expiration Date
Type/ Specialty
Do you have any conditional limitations or restrictions on your ability to practice under your professional License/ certification/ registration?

YesNo
Has your license/ certification/ registration ever been revoked?

YesNo
Please specify in detail
For Teacher Certification: Is your Certification initial, Provisional, Permanent, or Professional? Please specify

Potential for conflict of interest
4. Please provide the names of any relative(s) employed by the agency with which you are seeking employment. For the purposes of this application. a ‘relative‘ is defined as a person living in the same household. Parents, grandparents, spouse, siblings, children, aunts, uncles, nieces, nephews, and ln-laws.
Relative Name
Relationship to you
Check here if you have no relotlve(s) employed by the agency with which you are seeking employment.
Job interests and employment availability
(5) Name 2A position apply for
(6) If offered a position with the hiring agency. When would you be available for work?
Education

Applicants will be required to provide proof of diploma and/or degrees claimed.

	Name/Location	Credits	Diploma or Degree Received	Courses of Study(Major/Minor)
High School

Equivalency Program

	Issued by	Credits	Numbers
Vocational or Technical Schools
Vocational or Technical Schools
Vocational or Technical Schools
Colleges or Universities
Colleges or Universities.
Colleges or Universities
Other Training or Military Schools
Other Training or Military Schools
Other Training or Military Schools

Employment & Experience
Please list all periods of employment‘. beginning with the most recent. and include all prior experiences with any state or
local government. You must include all concurrent employment. Resumes will not be accepted in lieu of completing thls
Section. I! you need extra space please attach additional sheets. Agencies reserve the right to contact any or all of your
employers to verily the information provided.
Name of Present or Lost Employer
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date Employed
To
Supervisor's Name and Title
Salarly
Telephone

Area CodePhone Number
Your Title and Duties
Reason(s) for Leaving
If this is your current employer, when may we contact them?
Name of Present or Lost Employer
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date Employed
To
Supervisor's Name and Title
Salarly
Telephone

Area CodePhone Number
Your Title and Duties
Reason(s) for Leaving
Name of Present or Lost Employer
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date Employed
To
Supervisor's Name and Title
Salarly
Telephone

Area CodePhone Number
Your Title and Duties
Reason(s) for Leaving
If offered a position with this agency, will you also Intern, volunteer or maintain employment concurrently elsewhere?

YesNo
If “Yes' please identify any other concurrent employer and position(s). including self-employment
Employer
Positions Held
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please note that if you intend to maintain other employment while employed by the hiring agency, that agency's approval to do so may be required. Applicants should inquire about their ability to maintain other employment at the time of interview.

Professional References
Name

First NameLast Name
Relationship
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Telephone Number

Area CodePhone Number
Name

First NameLast Name
Relationship
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Telephone Number

Area CodePhone Number
Name

First NameLast Name
Relationship
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Telephone Number

Area CodePhone Number
Additional Remarks
Additional Remarks
Additional Sheets Attached?

YesNo
Applicant Affirmation & Release Authorization
I affirm that all statements made by me on this form. including attached papers. are true. complete and correct to the best of my knowledge. I understand all statements made by me in connection with this application are subject to investigation and veriﬁcation and that falsification or omission of information is cause for the revocation of offer of employment or dismissal from employment. I understand that knowingly making a false statement on this application or any attachment or supporting document is punishable as a misdemeanor pursuant to Section 210.45 of the NYS Penal Law.

I hereby authorize any former or current employer. military records center, or school to provide the New York State Department of Civil Service and/or the hiring authority any and all information necessary to reach an employment decision including. but not limited to, information regarding my job duties, attendance, behavior, work habits, skills, abilities, claims, liabilities, damage, and relationships with coworkers, customers or supervisors.
Signature
Date
Supplemental Information for Applicants
Applicants should retain a copy of this page for their records.

Additional Testing Required for Certain Positions: Physical/Medical examinations and/or drug and alcohol tests may be required for certain positions. Failure to participate in any required examinations and/or tests will negatively affect your employment eligibility and/or status.

Failure to provide the information or authorization will result in your application not being considered. The information will be maintained by the Director. Human Resources Management.

Policy: Employees of the TA should not have any interest. financial or otherwise, direct or indirect, or engage in any business or transaction or professional activity or incur any obligation of any nature, which is in substantial conflict with the proper discharge of their duties in the public interest.

TA shall avoid conflicts of interest when engaged in outside activity with or without compensation. Conﬂicts of interest include situations where an employee's conduct violates the public trust. Because of the diversity of the agency. employees should be especially cautious about possible conflict of interest when outside activities relate to the programs of the Department of State.

In addition, employees must not engage in activities other than official TA business during their scheduled working hours.
Supplemental Information for Applicants
Applicants should retain a copy of this page for their records.
Additionally, all employees holding a license or registration at the beginning of their employment with the Department may renew such licenses so that the license or registration status is maintained, but may not actually engage in the licensed occupation, except as specifically noted above.
Should be Empty:

Employment Application

Identifying Information

Application Information

Potential for conflict of interest

Job interests and employment availability

Education

Employment & Experience

Professional References

Additional Remarks

Applicant Affirmation & Release Authorization

Supplemental Information for Applicants

Supplemental Information for Applicants