Name*
Date*
Current Address*
Have you ever had a name change?*
Are you over 18 and under 65? *
Are you a U.S. Citizen?*

Note: Federal and State Human Rights laws prohibit discrimination in employment because of age, sex, national origin, race, color, creed, disability, marital status or handicap.

Have you ever been convicted of an unlawful offense (Excluding traffic violations)?*
Did you serve in the U.S. Armed Forces?*
Emergency Contact Name
Address*
Have you submitted an application previously?*
Have you ever worked for Crouse Community Center before?*
Are you presently employed? *
May we contact your present employer?*

Education

Registered Professional and Licensed Practical Nurse Applicants Only

Are you presently licensed to practice in New York State?
Are you registered in another state?

Certified Nursing Assistants Only

Are you currently registered in New York State?
If not, Have you applied?

Personal References

Give the names of three persons, NOT RELATIVES OR EMPLOYERS, who have known you for several years:

Name
Address
Name
Address
Name
Address

Previous Positions Held

List last three positions, last position listed first.

Employment Agreement

I understand that any false statements made as a part of this application will be considered sufficient cause for dismissal. I grantpermission for the authorities of the Crouse Community Center to investigate any and all information and release Crouse CommunityCenter from any and all liability resulting from such investigation.

I understand that employment at Crouse Community Center means that at any time when deemed necessary, I may be required to workrotating shifts or change my regular shift (if applicable) upon reasonable request.

I consent to any and all job related medical examinations required by Crouse Community Center and understand that if I am employed Iwill be on the applicable probationary period from date of employment. Upon my termination, I authorize the release of referenceinformation regarding my work.

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