Employment Application
Community Services for the Developmentally Disabled Inc.
452 Delaware Avenue   |   Buffalo, NY 14202-1515

Date of Application
Position(s) Applying For (please specify)

Select Here Day Hab Instructor Driver Habilitation Instructor Independent Living Skills Instructor Life Skills Trainer Night Support Staff Nurse - RN Service Coordinator Site Manager Stay Late Aide   Select Here Day Hab Instructor Driver Habilitation Instructor Independent Living Skills Instructor Life Skills Trainer Night Support Staff Nurse - RN Service Coordinator Site Manager Stay Late Aide Select Here Day Hab Instructor Driver Habilitation Instructor Independent Living Skills Instructor Life Skills Trainer Night Support Staff Nurse - RN Service Coordinator Site Manager Stay Late Aide   Select Here Day Hab Instructor Driver Habilitation Instructor Independent Living Skills Instructor Life Skills Trainer Night Support Staff Nurse - RN Service Coordinator Site Manager Stay Late Aide

Other:

Name (Last, First, Middle)
Phone #
Current Street Address
City
State
Zip Code
Previous Address (Street, City, State, Zip)
E-mail Address
Have you ever been employed  with Community Services for the Developmentally Disabled?	Yes No
If so, when and what position?
Do you have any restrictions, personal or otherwise, which would restrict the hours you can work?	Yes No
If yes, identify hours and/or dates restricted:
Are you prevented from lawfully becoming employed in this country because of Visa or immigration status?	Yes No (Proof of immigration status or citizenship will be required upon employment.)
Are you 18 years of age or older?	Yes No
If not, how old?	Do you have working papers? Yes No
Are you currently employed?	Yes No If not, how long since leaving last employment?
Rate of Pay Expected:

Education	NAME OF SCHOOL CITY AND STATE	Highest Grade Completed	Did you graduate?	Degree
High School		1   2  3   4	Yes    No
College(s)		1   2 3   4	Yes    No
Graduate School		1   2 3   4	Yes    No
Technical, Business, or Other		1   2 3   4	Yes    No

Employment History: (Start with your present or most recent position.  Include experience in the armed forces of the U.S.  Account for all periods of time.  Please fill out all information, even if attaching resume.)

Present Employer Name
Type of business:
Address
Phone number:
Starting date:
Starting position:
Starting earnings:
Leaving date:
Leaving duties:
Leaving earnings:
Reason for termination/separation:
Last immediate supervisor's name and title:

Second Employer Name
Type of business:
Address
Phone number:
Starting date:
Starting position:
Starting earnings:
Leaving date:
Leaving duties:
Leaving earnings:
Reason for termination/separation:
Last immediate supervisor's name and title:

Third Employer Name
Type of business:
Address
Phone number:
Starting date:
Starting position:
Starting earnings:
Leaving date:
Leaving duties:
Leaving earnings:
Reason for termination/separation:
Last immediate supervisor's name and title:

Character References: 2 references  (Not relatives)

No. 1

Name
Address
Occupation
Phone

No. 2

Name
Address
Occupation
Phone

Have you been convicted of a felony or misdemeanor with the exception of minor traffic offenses in any jurisdiction?
Yes No

If yes, please provide explanation:

City:
State:
Date:
Charge:
Disposition:

A response to the question below regarding pending arrests/criminal charges is not required of all applicants.  Please select the link below to see if the position you are applying for requires an answer to the question below.

View Here ACT Behavior Specialist ACT Habilitation Instructor ACT RN ACT Service Coordinator ACT Team Leader Assist Director of Housing and Shelter Behavior Specialist Budgeting Aide/Manager Day Habilitation Coordinator Day Habilitation Instructor and Lead Director of Housing and Shelter Director of Habilitation Services Director of Service Coordination Driver Employment Services Coordinator Family Habilitation Service Coordinator Family Violence Specialist Habilitation Instructor /relief Habilitation Instructor Habilitation Program Specialist Habilitation Service Coordinator Intensive Case Manager Individual Service Coordinator Investigator IRA Program Coordinator IRE counselor/relief ISE Habilitation Instructor / Lead Job Coach / Job Developer / Job Trainer Life Skills Trainer Night Support Staff Parenting Program Coord Placement Spec Registered Nurse RN -Supervisor Senior Day Progam Coordinator Senior Day Program Instructor Shelter Service Coordinator Site Manager Specialized Case Management Stay Late Aides Transitional Program Planner Transitional Specialist Vocational Case Manager  

Do you have any pending arrests/criminal charges?  Yes No

If yes, please provide explanation:
Your answer is looked upon as only one of the factors considered in the employment decision and is evaluated in terms of the nature, severity, and date of the offense.  No applicant will be excluded from consideration for employment due to prior arrests.

Have you ever been found guilty of child abuse?  Yes No

If yes, please provide explanation:

City:
State:
Date:
Charge:
Disposition:

A response to the question below regarding pending arrests/criminal charges is not required of all applicants.  Please select the link below to see if the site you are applying for requires an answer to the question below.

View Here Adolescent IRA Parenting IRA Safe House  

Do you have any pending arrests/criminal charges of child abuse?  Yes No

If yes, please provide explanation:

Describe specialized training, apprenticeships, skills and extra-curricular activities: summarize special skills and qualifications you have acquired from employment or other experience, including seminars or workshops completed.  Do not include any organization which may indicate your political affiliation, age, religion, national origin, color, marital status, sexual orientation, disability, veteran status, or other protected status.

Please indicate if you hold any of the following certifications (check all that apply).

First Aid     CPR     Medication    SCIP/R

Referral Source – Employee Name:

Newspaper Name:

Internet Site Name:

Other: (please specify)

Applicant's Agreement:
I hereby represent that each answer to a question herein and on any attachments to the application, and all other information otherwise furnished is true and correct.  I further represent that such answers and information constitute a full and complete disclosure of my knowledge with respect to the question or subject to which the answer or information relates.  I understand that any incorrect, incomplete or false statements or information furnished by me during the selection process will subject me to disqualification from consideration or discharge at any time.  I hereby authorize my former employers to give any information regarding my employment with them; and in addition, to furnish any other information they may have concerning me.

I understand this Application for Employment does not constitute an expressed or implied contract of employment and, if hired, I have the right to terminate my employment for any reason at any time. I also understand Community Services reserves the same rights.  I understand I may be subject to and I authorize Child Abuse, Criminal Background and Driving Abstract checks by Community Services.  I understand this may include the use of fingerprinting.  I understand Community Services reserves the right to unilaterally change or modify "wage" and "conditions of employment" at any time without previous notice.

I further understand that in the event I receive an offer of employment, I will be required to submit  to a post-offer drug test.  The offer of employment will be revoked, or employment will be terminated, in the event of a positive test result.  Any offer of employment will be revoked, or employment will be terminated based on adverse information obtained by Community Services or OMRDD during the background investigation process.

Name of Applicant
Date

 I understand by checking this box that I agree to the terms and conditions set forth in the above agreement.

Consumer Report Disclosure Statement

In compliance with the Fair Credit Reporting Act (Public Law 91-508), you are notified that in connection with and in order to better evaluate this application for employment, a report may be obtained which will provide applicable information concerning character, general reputation and personal characteristics including, but not limited to, verification of prior employment, verification with the Department of Motor Vehicles, and a character check, including verification and review of any criminal convictions.  You have the right to make a written request within a reasonable period of time for a complete and accurate disclosure of the nature and scope of the report requested.

I hereby authorize Community Services for the Developmentally Disabled to procure a consumer report as set forth above.

Name of Applicant
Date

 I understand by checking this box that I agree to the terms and conditions set forth in the above agreement.

Driver's Supplement

Driver's License Information. Must be completed by all applicants for positions that include driving as an essential function of the job.  Please click on the link below to see if the position you are applying for requires you to complete this section of the application.

View Here ACT Behavior Specialist ACT Habilitation Instructor ACT RN ACT Service Coordinator Apartment Manager Assist Director of Housing and Shelter Behavior Specialist Benefits Specialist Budgeting Aide/Manager Building & Property Coordinator Courier Day Habilitation Coordinator Day Habilitation Instructor and Lead Director of Housing and Shelter Director of Habilitation Services Director of Service Coordination Driver Employment Services Coordinator Family Habilitation Service Coordinator Family Violence Specialist Habilitation Instructor /relief Habilitation Instructor Habilitation Program Specialist Habilitation Service Coordinator Intensive Case Manager Individual Service Coordinator Investigator IRA Program Coordinator IRE counselor/relief ISE Habilitation Instructor / Lead Job Coach / Job Developer / Job Trainer Life Skills Trainer Maintance Supervisor Parenting Program Coord Placement Spec Property Main Tech Purchasing Spec Quality Assurance Coordinator Quality Assurance Specialist Registered Nurse RN -Supervisor Senior Day Progam Coordinator Senior Day Program Instructor Shelter Service Coordinator Site Manager Specialized Case Management Staff Development Coordinator Staffing Specialist Training Specialist Transitional Program Planner Transitional Specialist Transport Manager Vocational Case Manager

State:
Class:
Expiration Date:
Driver's License Endorsements:
Driver's License Restrictions:
A. Have you ever been denied a license, permit or privilege to operate a motor vehicle?	Yes    No
B. Has any license, permit or privilege ever been suspended or revoked by any state?	Yes    No
If the answer to either A or B is Yes, Please explain the details on the lines below.

Traffic Convictions And Forfeitures (for the past 3 years, do not list parking violations)
Alcohol or drug related offences for the past 5 years should be listed.

Court Location	Date of Conviction	Charge	Penalty	Points

Accident Record (for the past 3 years) (involving persons and/or property)

Date of Accident	Location - City, State	Nature of Accident	Fatal?

Use the space provided below to explain any of the above information concerning the accidents and traffic convictions listed:

Access to private transportation is an essential function of many Program positions.  Please click on the link below to see if the position you are applying for requires you to answer the question below.  Any individual accepting one of these positions will be required to use their private transportation throughout the day.  If you are applying for one of these positions, please answer the question below.

View Here ACT Behavior Specialist ACT Habilitation Instructor ACT RN ACT Service Coordinator ACT Team Leader Apartment Manager Assist Director of Housing and Shelter Behavior Specialist Benefits Specialist Budgeting Aide/Manager Building & Property Coordinator Day Habilitation Coordinator Day Habilitation Instructor and Lead Employment Services Coordinator Family Habilitation Service Coordinator Family Violence Specialist Habilitation Instructor /relief Habilitation Instructor Habilitation Program Specialist Habilitation Service Coordinator Intensive Case Manager Individual Service Coordinator Investigator IRA Program Coordinator IRE counselor/relief ISE Habilitation Instructor / Lead Job Coach / Job Developer / Job Trainer Maintance Supervisor Parenting Program Coord Placement Spec Property Main Tech Purchasing Spec Quality Assurance Coordinator Quality Assurance Specialist Registered Nurse RN -Supervisor Senior Day Progam Coordinator Senior Day Program Instructor Shelter Service Coordinator Specialized Case Management Staff Development Coordinator Staffing Specialist Training Specialist Transitional Specialist Vocational Case Manager  

Do you have access to private transportation to use while at work?  YES    NO

All persons who drive Community Services vehicles must have a valid New York State Driver's license.

I hereby represent that each answer to a question herein and on any attachments to the application, and all other information otherwise furnished is true and correct.  I further represent that such answers and information constitute a full and complete disclosure of my knowledge with respect to the question or subject to which the answer or information relates.  I understand that any incorrect, incomplete or false statements or information furnished by me during the selection process will