Application for Employment

In accordance with New York State law, WWAARC may contact the Department of Social Services to determine whether the applicant is the subject of an indicated child abuse and maltreatment report.

(Exclude Relatives & Previous Employers)

Has the Office of Professional Discipline of the New York State Education Department, the professional licensing board of another state, or any other body ever made a finding of professional misconduct against you, or entered into a settlement agreement with you?

Is there a professional disciplinary proceeding currently pending against you in the Office of Professional Discipline, the professional licensing board of another state, or any other body?

Please list at least the last 10 years of employment. Include all related experience in your employment history as well. Complete all applicable items, even if you have already submitted a resume (include month and year in all dates).

I certify that the information contained in this application and any accompanying documentation, and any information I provide throughout the hiring process is correct and complete to the best of my knowledge and belief. I realize that misrepresentation or omission of facts will be cause for rejection of this application or dismissal after employment, regardless of the timing or circumstances of discovery. I further understand that, should an offer of employment be extended by WWAARC, that employment will be “at will”, for no specified duration and may be terminated by myself or WWAARC at any time, with or without cause. No employee of WWAARC can enter into an employment contract for a specific period of time or make any agreement contrary to this policy without the written approval of the Board of Directors. I understand that WWAARC reserves the right to ensure the health and safety of staff and the individuals served by requiring PPD screening. I further agree that the WWAARC may contact all and any current and previous employers, schools, and references at any time during the application process for full information except as I have stated otherwise on this form. By this form, I hereby authorize, and direct employers, schools or persons named to give any information regarding my character, employment or education and hereby release said employers, schools or persons as well as WWAARC from all liability for any damages whatsoever in providing this information to WWAARC. I understand that as a condition of regular employment with WWAARC, I must demonstrate that I am insurable for vehicle/liability insurance. I understand that, as a condition of any such regular employment, I must maintain this insurability, if applicable to the position. I understand that, if I am applying for a position where I would have regular and substantial unsupervised, unrestricted physical contact with people receiving services, I must provide information statements and fingerprints necessary for a criminal history record check to be obtained and reviewed according to the requirements of sections 633.22. If the criminal history record information includes a conviction for one or more presumptive disqualifying crimes, the New York State Office for People with Developmental Disabilities shall issue a denial or direct WWAARC to issue a denial. I understand that I have the right to obtain, review, and seek corrections of my criminal history record information pursuant to regulations and procedures established by the New York State Division of Criminal Justice. I understand that I may withdraw my application for employment at any time before employment is offered or declined, regardless of whether WWAARC or I have reviewed my criminal history record information.

Our organization is an equal opportunity employer and government contractor. It has been and shall continue to be both the official policy and the commitment of the Company, including all its divisions to further equal employment opportunities in hiring or employment. Our organization is committed to the employment and advancement of minorities, females, individuals with disabilities, and veterans. No question on this form is intended to secure information to be used for such discrimination. If you fall into one of these protected classifications, we invite you to identify to yourself and receive coverage under our company’s Affirmative Action Plan. Completion of this form is voluntary and in no way affects the decision regarding your employment opportunity. Our organization is required by federal regulations to report information as requested below. The information provided will be held in the strictest confidence, will be maintained in a separate file, and will not be used in a manner inconsistent with the Acts. You may inform us of your status related to the following data or your change in status at this time and/or any time in the future.

Hispanic or Latino – A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race. White (Not Hispanic or Latino) – A person having origins in any of the original peoples of Europe, the Middle East, or North Africa. Black or African American (Not Hispanic or Latino) – A person having origins in any of the black racial groups of Africa. Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) – A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands. Asian (Not Hispanic or Latino) – A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. American Indian or Alaska Native (Not Hispanic or Latino) – A person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment. Two or More Races (Not Hispanic or Latino) – All persons who identify with more than one of the above five races.

This employer is a government contractor subject to the Vietnam Era Veterans’ Readjustment Assistance Act of 1974, as amended (Section 4212), which requires government contractors to take affirmative action to employ and advance in employment: (1) disabled veterans; (2) recently separated veterans; (3) active duty wartime or campaign badge veterans; and (4) Armed Forces service medal veterans. Our affirmative action policy prohibits discrimination and requires us to take affirmative action to employ and advance in employment qualified protected veterans at all levels of employment. The below invitation is made pursuant to this policy. Disclosure of this information is voluntary and refusing to provide it will not subject you to any adverse treatment. The information will be used only in ways that are consistent with Section 4212. The information you submit will be kept confidential, except that (i) supervisors and managers may be informed regarding restrictions on the work or duties of disabled veterans, and regarding necessary accommodations; (ii) first aid and safety personnel may be informed, when and to the extent appropriate, if you have a condition that might require emergency treatment; and (iii) government officials engaged in enforcing laws administered by the Office of Federal Contract Compliance Programs, or enforcing the Americans with Disabilities Act, may be informed. Protected veterans may have additional rights under USERRA—the Uniformed Services Employment and Reemployment Rights Act. In particular, if you were absent from employment in order to perform service in the uniformed service, you may be entitled to be reemployed by your employer in the position you would have obtained with reasonable certainty if not for the absence due to service. For more information, call the U.S. Department of Labor’s Veterans Employment and Training Service (“VETS”), toll-free, at 1–866–4–USA–DOL. INVITATION TO SELF-IDENTIFY PLEASE ANSWER THE FOLLOWING QUESTIONS Do you identify as one (or more) of the following protected veteran categories? Categories and definitions below. Please check the appropriate box below this section. NOTE: You do not have to indicate which specific category applies. Disabled Veteran: (i) a veteran of the U.S. military, ground, naval, or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veteran Affairs; or (ii) a person who was discharged or released from active duty because of a service-connected disability. Recently Separated Veteran: any veteran during the three-year period beginning on the date of such veteran’s discharge or release from active duty in the U.S. military, ground, naval, or air service. Armed Forces Service Medal Veteran: a veteran who, while serving on active duty in the U.S. military, ground, naval, or air service, participated in a United States military operation for which an Armed Forces medal was awarded pursuant to Executive Order 12985. Active Duty Wartime or Campaign Badge Veteran: a veteran who served on active duty in the U.S. military, ground, naval, or air service either during a “period of war” as defined below or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense. “Period of war” is defined for these purposes by the Department of Labor as: June 27, 1950 to January 31, 1955 (Korean conflict) February 28, 1961 to May 7, 1975 (for veterans serving in the Republic of Vietnam) August 5, 1964 to May 7, 1975 (for all other veterans who served during the Vietnam conflict) August 2, 1990 to the present (Gulf War)

Because we do business with the government, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities.i To help us measure how well we are doing, we are asking you to tell us if you have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will choose to fill it out. If you are applying for a job, any answer you give will be kept private and will not be used against you in any way. If you already work for us, your answer will not be used against you in any way. Because a person may become disabled at any time, we are required to ask all of our employees to update their information every five years. You may voluntarily self-identify as having a disability on this form without fear of any punishment because you did not identify as having a disability earlier.

You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition.

Blindness - Deafness - Cancer - Diabetes - Epilepsy - Autism - Cerebral palsy - HIV/AIDS - Schizophrenia Muscular dystrophy - Bipolar disorder - Major depression - Multiple sclerosis (MS) - Missing limbs or partially missing limbs - Post-traumatic stress disorder (PTSD) - Obsessive compulsive disorder - Impairments requiring the use of a wheelchair - Intellectual disability (previously called mental retardation)

The undersigned states the following concerning their driving record.

For the sole purposes of determining and evaluating my motor vehicle operating record and in accordance with State and Federal regulations, I

authorize Warren Washington Albany ARC (WWAARC), a chapter of The Arc New York to obtain my Motor Vehicle Record. I understand that this record may contain personal information* in addition to any/all driver violations and/or accidents, which may be on record through the Department of Motor Vehicles of whatever State in which I have most recently resided. I understand that as part of the application process for employment, WWAARC may order Motor Vehicle Records, through its insurance company and/or the Department of Motor Vehicles in connection with my application for employment. I also authorize WWAARC to provide my Motor Vehicle Record to insurance companies and to Local, State and/or Federal agencies or authorities as may be required or permitted by law. Should I be hired by WWAARC for employment, I understand that as a condition of regular employment with WWAARC, I must demonstrate my continued insurability with respect to vehicle/liability insurance. I understand, acknowledge and authorize WWAARC to obtain a photocopy my current driver’s license. I further authorize WWAARC and/or its vehicle/liability insurance company to perform checks and obtain reports of my driving record, on a regular basis with the New York State Department of Motor Vehicles or other State DMVs, as the case may be. I understand that as a condition of any such regular employment, I must maintain my insurability with respect to vehicle/liability insurance. I understand that I may request to know whether a Driver Vehicle Report was ordered, and WWAARC agrees to provide, upon my request, the name and address of the agency that furnished the report or information.