ATTENTION: HUMAN RESOURCES DEPARTMENT

117 EAST STEUBEN STREET, BATH, N.Y. 14810 PH: 607-776-2125/1-800-553-2033 FAX: 607-776-2723

APPLICATION FOR EMPLOYMENT

(PLEASE PRINT)

Pro Action considers applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, marital or veteran status, sexual orientation, or any other legally protected status.

Position(s) Applying For:_____________________________________________________________________________

Date of Application:__________________ Full-time ________ Part-time ________ Substitute _________

Site Location Desired: ________________________ Department: _____________________________________

How Did You Learn About Us?

____Advertisement ____Friend ____Walk-In

____Employment Agency ____Relative ____Other_______________

Last Name:_______________________ First Name:_______________________ Middle Name_____________

Address:_____________________________________________City:_____________________State:________

Zip Code:_____________ Telephone Number (s): _________________________________________________

If the position requires, are you a licensed driver with a clean and valid driving record? Yes_____ No_____

State issuing license:__________ Type of license: _________________________________________________

Do you own a car?_________ Can you travel for meetings/conferences, if position requires:________________

Are you currently employed?________ May we contact your present employer:__________________________

NOTE TO APPLICANTS: DO NOT ANSWER THE FOLLOWING QUESTION UNLESS YOU HAVE BEEN INFORMED ABOUT THE REQUIREMENTS OF THE JOB FOR WHICH YOU ARE APPLYING.

Are you capable of performing in a reasonable manner, with or without a reasonable accommodation, the activities involved in the job/occupation for which you have applied? Yes_____ No______

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EDUCATION

Name Address Course of Study Graduated/Type of Degree

High School:

College:

Trade/Technical/Business School:

Graduate School:

Subjects of Special Study: ____________________________________________________________________________

List professional, trade, business or civic activities and offices held. (Do not include information regarding gender, race, religion, national origin, age, ancestry, disability or other protected statuses.): _________________________________

_________________________________________________________________________________________________

Hobbies and Interests:_______________________________________________________________________________

EMPLOYMENT HISTORY

(List your last three employers, starting with the most recent one first)

Dates From/To Employer Name and Address Position Held Reason for Leaving

REFERENCES

Name Address Phone Occupation Years Known

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ATTENTION: HUMAN RESOURCES DEPARTMENT

117 EAST STEUBEN STREET, BATH, N.Y. 14810 PH: 607-776-2125/1-800-553-2033 FAX: 607-776-2723

APPLICANT=S RELEASE AND STATEMENT

I give permission to Pro Action of Steuben and Yates, Inc. to obtain professional, personal and educational references necessary to make a hiring decision and hold persons and/or organizations giving references harmless and free of any and all liability that could result from this process.

A copy, photostat, or facsimile of this authorization shall be given the same force and effect as the original.

Applicant Signature:_______________________________________________Date:____________________

*******************************************************************************

I certify that the information provided regarding my qualifications for employment are true and correct to the best of my knowledge. I authorize investigation and inquiries of all statements as necessary in arriving at an employment decision.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an Aat will@ nature, which means that the Employee may resign at any time and the Employer may discharge the Employee at any time with or without cause. It is further understood that this Aat will@ employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization.

In the event of employment, I understand that false or misleading information given may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.

Applicant=s Signature:________________________________________Date:_________________________

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117 E. Steuben Street , Bath, New York 14810

Phone 607-776-2125 Fax 607-776-2723

Mission Statement

To promote the creation

of quality family life,

self-sufficiency,

and the ability to thrive

for all people in our

community.

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