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LDA Employment Opportunities - Application

Please fill out this form to apply for the post of Educational Consultant
* = Required
Personal Information
First Name: * Middle
Last Name: *
Address: *
City: *
State: *
Zip: *
Telephone Number: *
Alternate Number:
Email:
Position Desired: *
Salary Desired:
Education Information
Education Name and Location of School Course of Study Degree Earned Years in School
High School * * * *
 
College
 
Post Graduate
 
Employment History (Start with current or most recent employer)
Are you legally eligible to work in the United States? *    Yes   No
If you are hired, you will be required to furnish proof of legal authorization to work in the United States.
Dates To
Name/City
Position
Outline of Duties
Salary
Supervisor/Title
Reason for Leaving
Dates To
Name/City
Position
Outline of Duties
Salary
Supervisor/Title
Reason for Leaving
Dates To
Name/City
Position
Outline of Duties
Salary
Supervisor/Title
Reason for Leaving
Dates To
Name/City
Position
Outline of Duties
Salary
Supervisor/Title
Reason for Leaving
Additional Information
List any professional licenses or certifications pertinent to the job for which you are applying.
List any other human services employment pertinent to the job for which you are applying.
Please give any details of your life experiences or skills which you feel are relevant to the position for which you are applying.
How did you hear about this job? *
Have you ever been employed by LDA? *    Yes No
Personal References (You must provide two personal references.)
Name Address Phone Number Years of Acquaintance
* * * *
* * * *
Background Information and Checks
Per New York State law, fingerprinting and a criminal background check are required for all direct care employees. In addition, the agency also runs a Medicaid fraud background check and a driver's license check. A decision to continue the employment process will be made after the drivers license check and Medicaid fraud checks are completed. A further determination and recommendation for continued employment with the agency will be made after the New York State Criminal Background Check Unit results are received.
Do you have a current driver's license? *    Yes No
Do you have a currently licensed and insured vehicle? *    Yes No
Has your license EVER been suspended or revoked? *    Yes No
Have you been convicted of ANY violations in the last three (3) years?
* Yes No

If yes to either of the last two questions give date(s) and details of conviction.

NOTE: List ALL drivers license suspensions and/or revocations.

NOTE: List ALL violations in the last three years except parking tickets.

Have you ever had a DUI or DWI conviction or any occurrence involving harm to persons or property while driving? *
Yes No

If yes, give date(s) and details.

Have you ever been convicted of a felony or misdemeanor? *
Yes No

If yes, give the date and nature of the charge and conviction.

Are there any criminal charges pending against you now? *
Yes No

If yes, give date and nature of charges.
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Resume
Applicant Statement
I authorize investigation of all statements contained in this application and hereby certify that all of the information provided by me in this application (or any other accompanying or required documents) is correct, accurate and complete. I understand that the falsification, misrepresentation or omission of any facts in said documents will be grounds for denial of employment or immediate termination of employment regardless of the timing or circumstances of the discovery. Furthermore, I understand and agree that my employment is for no definite period of time and may be terminated at any time without previous notice, as New York State is an "employment at will" state.

DO NOT COMPLETE UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT.

* I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement.

LDA LIFE AND LEARNING SERVICES IS AN EQUAL OPPORTUNITY EMPLOYER. ALL QUALIFIED APPLICANTS WILL RECEIVE CONSIDERATION WITHOUT REGARD TO RACE, COLOR, RELIGION, GENDER, NATIONAL ORIGIN, AGE, DISABILITY, VETERAN STATUS OR ANY OTHER STATUS PROTECTED BY LAW.