APPLICATION FOR EMPLOYMENT Rescue Mission of Utica 212 Rutger Street Utica, NY Phone (315) Fax (315)

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1 APPLICATION FOR EMPLOYMENT Rescue Mission of Utica 212 Rutger Street Utica, NY Phone (315) Fax (315) Mission Statement The Rescue Mission of Utica (RMU) is a Christian ministry unconditionally endeavoring to assess and meet the physical, emotional and spiritual needs of people coming for assistance. We are an Equal Opportunity Employer. We consider all applicants for all positions without regard to race, color, religion, creed, gender, sexual orientation, national origin, age, disability, genetic predisposition or carrier status, marital status, pregnancy, military or veteran status or any other legally protected status. The Rescue Mission of Utica is committed to providing a safe and healthy work environment; accordingly smoking and the use of drug or tobacco products is prohibited on the entire RMU campus including RMU vehicles. Application Instructions Please fill out this application completely. Attach a resume, but doing so does not excuse you from filling in required fields on the application. Please note: you may not be considered for employment if you do not fill out this application in its entirety and if you do not sign on the fourth page. Position(s) Applied for: Walk-in Department of Labor RMU Website Other Website (PLEASE USE INK AND PRINT CLEARLY) Date of Application: Referral Source (Please indicate referral source): Friend/Relative Employee Referral Advertisement Other Last Name: First Name: Middle: Maiden Name: Address: City: State: Zip Code: Phone Number: Address: Alternate Number: Are you at least 18 years of age? Have you ever filed an application with RMU? If yes, please give date(s): Have you ever been employed, volunteered or interned with RMU? If yes, date(s) of employment: / / to / / Position: date(s) of volunteer time: / / to / / Program: date(s) as intern: / / to / / Program: 212 Rutger Street Utica, NY Phone (315) Fax (315) (- 1 -)

2 Date available for work: Desired Pay Rate/Salary: $ Are you available to work holidays? Are you available to weekends? Are you currently on lay-off status and subject to recall? Desired type of employment: Full-time Part-time Per Diem Temporary (Check all that apply) Desired shift(s): 1 st 2 nd 3 rd 8 hour shift (over 8 hours) (Check all that apply) Name of Applicant: EMPLOYMENT HISTORY List most recent employment first. Are you currently employed? If yes, why are you looking for a new position? May we contact your current employer? N/A If no, when may we contact your employer? Date: / / Employer: Address: Job Title: Phone: Dates Employed: / / to / / Final Salary: Supervisor Name: Supervisor Reason for Leaving: Employer: Address: Dates Employed: / / to / / Final Salary: Supervisor Name: Supervisor Reason for Leaving: Employer: Address: Dates Employed: / / to / / Final Salary: Supervisor Name: Supervisor Reason for Leaving: Job Title: Phone: Job Title: Phone: Date of Application: Is this your complete employment history? If no, please explain and elaborate on any employment gaps: Do you have a copy of your last job performance evaluation available for us to review? Yes If yes, please attach or forward a copy to the Human Relationships Department. No 212 Rutger Street Utica, NY Phone (315) Fax (315) (- 2 -)

3 EDUCATIONAL BACKGROUND Name and Address of School Attended High School College/ University Graduate School Professional or Trade Schools Other(specify) Course of Study Did you Graduate? Degree/Major Earned LPN: License Number: Certification Number: Expiration Date: / / RN: License Number: Certification Number: CASAC: Yes Expiration Date: / / No Credential Number: Expiration Date: / / CPR Certified: Recommended Renewal Date: / / AED Certified: Recommended Renewal Date: / / First Aid Certified: Recommended Renewal Date: / / (Please forward copy(s) of licenses and certifications to Human Relationships Department) Provide your driver s license ID number only if it is a requirement of the position you are applying for. Do you have a valid driver s license? N/A State where issued: License #: Please indicate whether you have experience in the following programs: Microsoft Word Microsoft Excel Microsoft Outlook Microsoft PowerPoint Microsoft Publisher ADP Client tracking software Other List any specialized training, certifications, apprenticeships, special job-related skills or qualifications from other employment/volunteer experiences that are relevant to the job for which you are applying: 212 Rutger Street Utica, NY Phone (315) Fax (315) (- 3 -)

4 PROFESSIONAL REFERENCES List three professional references that have supervised your work/school performance. No friends or relatives please. Name: Years Known: Relationship: Address: Telephone #: Name: Years Known: Relationship: Address: Telephone #: Name: Years Known: Relationship: Address: Telephone #: ACKNOWLEDGMENT & AUTHORIZATION STATEMENT (Please read carefully, initial each paragraph and sign below) I certify that all information and responses I have provided in this application are true and complete. I understand that a material omission or misrepresentation in the application process will disqualify me from further consideration of employment, withdrawal of any offer of employment or termination of employment, if hired. I authorize The Rescue Mission of Utica to verify all of the information I have provided on the Application for Employment, as well as any additional information needed to consider my application for employment. I authorize all previous employers, educational institutions, references and other persons who have knowledge of me and/or my records to provide any and all information pertinent to my employment and release the same from any liability resulting from providing such information. I also release this organization and all of its employees from all liability for any damage that may result from reliance on the information furnished. I understand that, pursuant to the requirements of the Rescue Mission of Utica s regulatory agencies, I may be required to provide additional information and complete a background screening process which may include fingerprinting. After a conditional offer of employment has been made, if requested, I agree to take a job-related medical examination/health assessment or other screenings at no personal expense, determined by the program into which I am being considered for hire. I authorize the examining medical provider to disclose the findings of such exams to the Rescue Mission of Utica. The Rescue Mission of Utica is committed to providing a drug and alcohol-free workplace. After receiving a conditional offer of employment, I understand that a drug test will be required before starting work. If the results of the test are positive, I understand that the offer of employment will be withdrawn. If employed, I agree to abide by all policies, procedures, rules and regulations of the organization. Unless otherwise defined by applicable law, any potential employment relationship with the Rescue Mission of Utica is of an at will nature. I understand and agree that, if hired, my employment is for no definite period and may, regardless of the date of payment of my wages or salary, be terminated by myself or the Rescue Mission of Utica at any time with or without cause or notice. I further understand that the policies, procedures, rules and benefits contained in the employee handbook, benefit plans and other written documents should not be considered an employment contract for any period of time. I acknowledge receipt of a copy of Article 23-A of New York Correction Law located on the last page of this application. Applicant Name (Print) Applicant Signature Date 212 Rutger Street Utica, NY Phone (315) Fax (315) (- 4 -)

5 A conviction(s) is not an automatic bar from employment. Each case is evaluated according to the duties and responsibilities of the position for which you are applying. Have you ever been convicted of a misdemeanor or felony that was not dismissed, expunged, or sealed? If yes, please describe fully the criminal conviction(s), listing the nature of the offense, the year at the time of the offense and your rehabilitation since the conviction(s) in the space provided below. Are you under investigation or have you been sanctioned by the Office of Professional Discipline, the NYS Justice Center, OMH, OASAS or similar licensure/certification monitoring agency? If yes, please provide dates of the occurrence(s) and monitoring agency s specific allegations. Provide response only if you are applying for a position in the Finance or Rep-Payee Departments. Have you ever been investigated or sanctioned from participating in Medicare or Medicaid Programs? N/A If yes, please provide dates of the occurrence(s) and specify the allegations. Provide response only if driving is a requirement of the position for which you are applying. Have you had any convictions against the Vehicle and Traffic laws of New York State or and other state? N/A If yes, please provide dates of the occurrence(s) and specify the allegations and state of convictions. 212 Rutger Street Utica, NY Phone (315) Fax (315) (- 5 -)

6 NEW YORK CORRECTION LAW - ARTICLE 23-A LICENSURE AND EMPLOYMENT OF PERSONS PREVIOUSLY CONVICTED OF ONE OR MORE CRIMINAL OFFENSES 750. Definitions. For the purposes of this article, the following terms shall have the following meanings: (1) "Public agency" means the state or any local subdivision thereof, or any state or local department, agency, board or commission. (2) "Private employer" means any person, company, corporation, labor organization or association which employs ten or more persons. (3) "Direct relationship" means that the nature of criminal conduct for which the person was convicted has a direct bearing on his fitness or ability to perform one or more of the duties or responsibilities necessarily related to the license, opportunity, or job in question. (4) "License" means any certificate, license, permit or grant of permission required by the laws of this state, its political subdivisions or instrumentalities as a condition for the lawful practice of any occupation, employment, trade, vocation, business, or profession. Provided, however, that "license" shall not, for the purposes of this article, include any license or permit to own, possess, carry, or fire any explosive, pistol, handgun, rifle, shotgun, or other firearm. (5) "Employment" means any occupation, vocation or employment, or any form of vocational or educational training. Provided, however, that "employment" shall not, for the purposes of this article, include membership in any law enforcement agency Applicability. The provisions of this article shall apply to any application by any person for a license or employment at any public or private employer, who has previously been convicted of one or more criminal offenses in this state or in any other jurisdiction, and to any license or employment held by any person whose conviction of one or more criminal offenses in this state or in any other jurisdiction preceded such employment or granting of a license, except where a mandatory forfeiture, disability or bar to employment is imposed by law, and has not been removed by an executive pardon, certificate of relief from disabilities or certificate of good conduct. Nothing in this article shall be construed to affect any right an employer may have with respect to an intentional misrepresentation in connection with an application for employment made by a prospective employee or previously made by a current employee Unfair discrimination against persons previously convicted of one or more criminal offenses prohibited. No application for any license or employment, and no employment or license held by an individual, to which the provisions of this article are applicable, shall be denied or acted upon adversely by reason of the individual's having been previously convicted of one or more criminal offenses, or by reason of a finding of lack of "good moral character" when such finding is based upon the fact that the individual has previously been convicted of one or more criminal offenses, unless: (1) There is a direct relationship between one or more of the previous criminal offenses and the specific license or employment sought or held by the individual; or (2) The issuance or continuation of the license or the granting or continuation of the employment would involve an unreasonable risk to property or to the safety or welfare of specific individuals or the general public Factors to be considered concerning a previous criminal conviction; presumption. 1. In making a determination pursuant to section seven hundred fifty-two of this chapter, the public agency or private employer shall consider the following factors: (a) The public policy of this state, as expressed in this act, to encourage the licensure and employment of persons previously convicted of one or more criminal offenses. (b) The specific duties and responsibilities necessarily related to the license or employment sought or held by the person. (c) The bearing, if any, the criminal offense or offenses for which the person was previously convicted will have on his fitness or ability to perform one or more such duties or responsibilities. (d) The time which has elapsed since the occurrence of the criminal offense or offenses. (e) The age of the person at the time of occurrence of the criminal offense or offenses. (f) The seriousness of the offense or offenses. (g) Any information produced by the person, or produced on his behalf, in regard to his rehabilitation and good conduct. (h) The legitimate interest of the public agency or private employer in protecting property, and the safety and welfare of specific individuals or the general public. 2. In making a determination pursuant to section seven hundred fifty-two of this chapter, the public agency or private employer shall also give consideration to a certificate of relief from disabilities or a certificate of good conduct issued to the applicant, which certificate shall create a presumption of rehabilitation in regard to the offense or offenses specified therein Written statement upon denial of license or employment. At the request of any person previously convicted of one or more criminal offenses who has been denied a license or employment, a public agency or private employer shall provide, within thirty days of a request, a written statement setting forth the reasons for such denial Enforcement. 1. In relation to actions by public agencies, the provisions of this article shall be enforceable by a proceeding brought pursuant to article seventy-eight of the civil practice law and rules. 2. In relation to actions by private employers, the provisions of this article shall be enforceable by the division of human rights pursuant to the powers and procedures set forth in article fifteen of the executive law, and, concurrently, by the New York city commission on human rights. *Effective February 1, 2009, employers must post a copy of the Correction Law relating to the use of prior convictions.

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