Please print this page off, then fill it out and fax it to: 585-272-8851
Application for Employment
equal access to programs, services and employment is available to all persons. Those applications requiring accomidation to the application and/or interview process should contact a representative of the personel department.
Please Print
Position(S) applied for _________________________Date of application____/____/____
Name: Last_________________  First__________________ Middle _______________
Address:___________________________City: ____________ State:______ Zip:______
Telephone (____)_______________  Social Security #: _________-_______-_________
If you are under 18 can you furnish a work permit?.......................................___Yes ___ No
Have you ever been employed here before?..................................................___Yes ___ No
Are you legally eligeble for employment in this country?.................................___Yes ___ No
(Proof of U.S. Citizenship will be required upon employment.)
Date available for work ................................................................................____/____/____
Type of employment desired?__ Full Time__Part Time__Temporary__Seasonal __Educational co-op
Are you able to meet the attendance requirmentsfor this position?....................___Yes___No
Have you been convicted of a felony in the past 7 years?.................................___Yes___No
(Such conviction may be relevant if job related, but does not bar you from employment)
If yes please explain_______________________________________________________
Drivers License # (if job related)______________________________State____________
Employment History
List your last four (4) employers, assignments or volunteer activities, starting with the most recent, including military experience.
From_____ To_____ Employer_________________ Phone: (__)_________
Job Title___________ Address_____________________________________
Immediate supervisor & title Summarize the nature of worked performed and job responsibilities
_________________ __________________________________________
Reason for leaving______ Hourly Rate/Salary  Start $________ Per_____ Final $_____ Per_____
From_____ To_____ Employer_________________ Phone: (__)_________
Job Title___________ Address_____________________________________
Immediate supervisor & title Summarize the nature of worked performed and job responsibilities
_________________ __________________________________________
Reason for leaving______ Hourly Rate/Salary  Start $________ Per_____ Final $_____ Per_____
From_____ To_____ Employer_________________ Phone: (__)_________
Job Title___________ Address_____________________________________
Immediate supervisor & title Summarize the nature of worked performed and job responsibilities
_________________ __________________________________________
Reason for leaving______ Hourly Rate/Salary  Start $________ Per_____ Final $_____ Per_____
From_____ To_____ Employer_________________ Phone: (__)_________
Job Title___________ Address_____________________________________
Immediate supervisor & title Summarize the nature of worked performed and job responsibilities
_________________ __________________________________________
Reason for leaving_______ Hourly Rate/Salary  Start $________ Per_____ Final $_____ Per_____
Skills and Qualifications:
Summarize any training, skills, licenses, certificates and/or characteristics of yourself that may qualify you as being able to perform job-related functions for the position which you are applying.
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Educational Background (if job related)
Name & Location: Years Completed: Did you graduate?: Course of study:
High School_________________ _____ _____ ____________
College____________________ _____ _____ ____________
Other_____________________ _____ _____ ____________
References:
Name: Telephone: Years Known:
____________________________________ (___)_____________ _____
____________________________________ (___)_____________ _____
____________________________________ (___)_____________ _____
It is understood and agreed upon that any misrepresentation by me on this application will be sufficient cause for cancellation of this application and/or separation from the employer's services if I have been employed.

I give the employer the right to investigate all references and to secure additional information about me, if job-related. I hearby release from liability the employer and its representatives for seeking such information, and all other persons, corporations or organizations for furnishing such information.

The employer is an equal opportunity employer. The employer does not discriminate in employment and no question on this applications used for the purpose of limiting or excusing any applicant's consideration for employment on a basis prohibited by local, state or federal law.

This application is current for only 60 days. At the conclusion of this time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary to fill out a new application.

I understand that just as I am free to resign at any time, the employer reserves the right to terminate my employment at any time, with or without cause and without prior notice. I understand that no representative of the employer has the authority to make any assurances to the contrary.

I understand it is this company's policy not to refuse to hire a qualified individual because of this person's need for an accomidation that would be required by the ADA. 
Signature of Applicant_________________________________   Date ____/____/____