Fillable Printable Employment Application (pdf) - New York State Parks
Fillable Printable Employment Application (pdf) - New York State Parks
Employment Application (pdf) - New York State Parks
NYS Employment Application: Part 1 Pre-Interview Form #S1000 1 July 2015
1. All candidates must be eligible for employment in the United States and maintain this
eligibility throughout their employment with NYS. Employment is contingent upon the
provision of proof of the right to accept employment in the United States.
a. Are you legally authorized to work in the United States?
b. Will you now, or in the future, require sponsorship for employment visa status
(e.g. for an H-1B Visa)?
c. If under age 18, can you provide a work permit?
2. Certain positions may require extensive travel within a designated area of assignment;
to otherwise travel in areas that may not be served by public transportation; to routinely
operate a motor vehicle; and/or to routinely operate heavy equipment requiring a specialized
license.
For positions requiring operation of a motor vehicle or heavy equipment, appointees must
possess a driver license valid in NYS at the time of appointment and continuously thereafter.
Candidates who do not possess a driver license valid in NYS must be able to demonstrate
their capacity to meet the transportation needs of the job at the time of interview.
a. Do you currently have a valid driver license that allows you to operate a motor vehicle
in New York State? Ye
b. If yes, please select your license class: CDL A B C D E Other (specify)
Licensing State: License Number:
EMPLOYMENT APPLICATION
PART 1 – PRE-INTERVIEW
New York State (NYS) is an equal opportunity/armative action employer. NYS Law prohibits discrimination because
of age, race, creed, color, national origin, sexual orientation, military status, sex, disability, predisposing genetic
characteristics, marital status, domestic violence victim status, carrier status, gender identity or prior conviction records, or
prior arrests, youthful oender adjudications, or sealed records unless based upon a bona fide occupational qualification
or other exception.
If you are a person with a disability and wish to request that a reasonable accommodation be provided for you to
participate in a job interview, please contact:
IDENTIFYING INFORMATION
APPLICANT INFORMATION
Please read all instructions carefully. All pages of this application must be completed, and the application signed. If you
need additional space, please use the ADDITIONAL REMARKS section. Applicants may be required to complete additional
components of the Employment Application as directed by the hiring agency. Part 2 of the New York State Employment
Application must be completed by Applicants after the interview process.
Name:
Current Mailing/Street Address:
City State Zip Code
Email Address:
Permanent Street Address (if dierent from above):
List any other names by which you have been
known (including nicknames):
XXX/XX/
SSN (last 4 digits only)
NYS EMPLID (if assigned)
( )
Home Phone
( )
Business Phone
( )
Cell Phone
POSITIONS MAY REQUIRE TRAVEL AND/OR OPERATION OF A MOTOR VEHICLE OR HEAVY EQUIPMENT
Form #S1000
Michael Washington, 518/486-9397
NYS Employment Application: Part 1 Pre-Interview Form #S1000 2 July 2015
c. For Commercial Driver License (CDL) holders, please list your endorsements or
restrictions:
d. Have you ever had your driver license revoked or suspended? Yes ☐ No ☐ N/A ☐
If yes, please explain:
3. For some positions, professional licensure, registration, certification, or other authorization
to practice a trade or profession is required. Applicants claiming these credentials will be
required to provide proof as a part of the screening process. If you are required to possess
such credentials for the position you are applying for, please complete the following
questions:
a. Name of Trade or Professional License/Certificate:
License No.: Issued By: Issue Date:
Expiration Date: Registration Date:
Registration Expiration Date: Type/Specialty:
b. Do you have any conditional limitations or restrictions on your ability to practice
under your professional license/certification/registration? Yes ☐ No ☐ N/A ☐
c. Has your license/certification/registration ever been revoked? Yes ☐ No ☐ N/A ☐
If yes to 3b or 3c, please specify in detail:
d. For Teacher Certification: Is your Certification Initial, Provisional, Permanent, or
Professional? Please specify:
4. Please provide the names of any relative(s) employed by the agency with which you are
seeking employment. For the purposes of this application, a “relative” is defined as a person
living in the same household, parents, grandparents, spouse, siblings, children, aunts,
uncles, nieces, nephews, and in-laws.
Relative Name: Relationship to you:
☐ Check here if you have no relative(s) employed by the agency with which you are seeking employment.
5. Please provide the names of any entity (Business or Vendor) or describe any connection you
have to any entity doing business with the agency with which you are seeking employment.
If a relative, as defined in Question 4, is affiliated with, or owns an entity doing business with
NYS, use this section to describe the connection to you.
Name of Entity with which you have a connection:
Describe the connection and any relationship to you:
☐ Check here if you have no relationship or connection to any entity doing business with NYS.
6. Type of work or position desired:
7. Geographic work location(s) desired:
8. Some positions require different work schedules.
Please indicate which schedules you would be able to perform:
9. If offered a position with the hiring agency, when would you be available for work?
JOB INTERESTS AND EMPLOYMENT AVAILABILITY
POTENTIAL FOR CONFLICT OF INTEREST
Hours
Shift Work
Overtime
Ability to Work
Yes ☐ No ☐
Yes ☐ No ☐
Schedule
Saturday hours
Sunday hours
Full-time
Part-time
Per diem
Ability to Work
Yes ☐ No ☐
Yes ☐ No ☐
Yes ☐ No ☐
Yes ☐ No ☐
Yes ☐ No ☐
Duration
Permanent
Temporary
Seasonal
Summer Only
Winter Only
Ability to Work
Yes ☐ No ☐
Yes ☐ No ☐
Yes ☐ No ☐
Yes ☐ No ☐
Yes ☐ No ☐
POSITIONS MAY REQUIRE PROFESSIONAL LICENSURE OR CERTIFICATION
NYS Employment Application: Part 1 Pre-Interview Form #S1000 3 July 2015
School
High school
Equivalency Program
Vocational or Technical
Schools
Colleges or Universities
Other Training or
Military Schools
Name/Location
EMPLOYMENT & EXPERIENCE
EDUCATION
Credits
Diploma or Degree
Received
Courses of Study
(Major/Minor)
Issued by: Number:
Please list all periods of employment*, beginning with the most recent, and include all prior experiences with any state or
local government. You must include all concurrent employment. Resumes will not be accepted in lieu of completing this
Section. If you need extra space please attach additional sheets. Agencies reserve the right to contact any or all of your
employers to verify the information provided.
Name of Present or Last Employer:
Address: Date Employed: / /
Supervisor’s Name and Title: To / /
Salary:$ Telephone: ( )
Your Title and Duties:
Reason(s) for Leaving:
If this is your current employer, when may we contact them?
Name of Present or Last Employer:
Address: Date Employed: / /
Supervisor’s Name and Title: To / /
Salary:$ Telephone: ( )
Your Title and Duties:
Reason(s) for Leaving:
Name of Present or Last Employer:
Address: Date Employed: / /
Supervisor’s Name and Title: To / /
Salary:$ Telephone: ( )
Your Title and Duties:
Reason(s) for Leaving:
*Attach additional sheets as needed
Applicants will be required to provide proof of diploma and/or degrees claimed.
NYS Employment Application: Part 1 Pre-Interview Form #S1000 4 July 2015
Additional Sheets Attached? Yes ☐ No ☐
I affirm that all statements made by me on this form, including attached papers, are true, complete and
correct to the best of my knowledge. I understand all statements made by me in connection with this
application are subject to investigation and verification and that falsification or omission of information is
cause for the revocation of offer of employment or dismissal from employment. I understand that knowingly
making a false statement on this application or any attachment or supporting document is punishable as a
misdemeanor pursuant to Section 210.45 of the NYS Penal Law.
I hereby authorize any former or current employer, military records center, or school to provide the New York
State Department of Civil Service and/or the hiring authority any and all information necessary to reach an
employment decision including, but not limited to, information regarding my job duties, attendance, behavior,
work habits, skills, abilities, claims, liabilities, damage, and relationships with coworkers, customers or
supervisors.
Signature: Date:
10. If offered a position with this agency, will you also intern, volunteer or maintain
employment concurrently elsewhere? Yes ☐ No ☐
If “Yes” please identify any other concurrent employer and position(s), including
self-employment:
Employer: Positions Held:
Employer Address:
Please note that if you intend to maintain other employment while employed by the hiring agency, that agency’s
approval to do so may be required. Applicants should inquire about their ability to maintain other employment at
the time of interview.
ADDITIONAL REMARKS
APPLICANT AFFIRMATION & RELEASE AUTHORIZATION
Name: Relationship:
Address: Telephone Number: ( )
Email Address:
Name: Relationship:
Address: Telephone Number: ( )
Email Address:
Name: Relationship:
Address: Telephone Number: ( )
Email Address:
PROFESSIONAL REFERENCES
NYS Employment Application: Part 1 Pre-Interview Form #S1000 5 July 2015
SUPPLEMENTAL INFORMATION FOR APPLICANTS
Applicants should retain a copy of this page for their records.
Additional Testing Required for Certain Positions: Physical/Medical examinations and/or drug and
alcohol tests may be required for certain positions. Failure to participate in any required examinations and/or
tests will negatively aect your employment eligibility and/or status.
Former State or Local Government Retirees: Section 150 of the Civil Service Law of New York State
prohibits retired state or local employees from being rehired by the state or a political subdivision and
receives pension benefits while employed. Applicants who are receiving service retirement benefits from
New York State, Municipal or Political Subdivision Retirement System must have approval under Section 211 or
212 of the Retirement and Social Security Law to protect their current service benefits.
Post-Employment Restrictions: Post-employment restrictions apply to all State Ocers and Employees
subject to Public Ocers Law Section 73. They apply to part-time and seasonal employees, and apply equally
regardless of the duration of employment while with New York State. For the two year period immediately
following separation from State service, former State Ocers and Employees are prohibited from:
a. Appearing or practicing, regardless of compensation, before their former agency,
and
b. Receiving compensation on behalf of a client in relation to a matter before their former agency.
State Ocers and Employees may also be subject to a “
reverse two-year bar” that requires State ocers
and employees to recuse themselves from matters involving their former private sector employers for two
years after entering State service.
The “
lifetime bar” prohibits a former State Ocer or Employee from providing services, regardless of
compen
sation, and from rendering services for compensation, in relation to any case, proceeding, application
or transaction with respect to which the former employee was directly concerned and in which he or she
personally participated or which was under his or her active consideration while in State service.
Personal Privacy Protection Law Notification
The information you are providing on this application is being requested for the principal purpose of determining
eligibility for initial and continued employment. The information may also be used in administering employee benefit
programs and will be used in accordance with Section 96(1) of the Personal Privacy Protection Law. Failure to provide
the requested information may hinder your possible hiring and the subsequent administration of your employee
benefits.
Annual Salaried Positions
The information will be maintained by the Director of Personnel, Oce of Parks, Recreation and Historic Preservation,
Albany, New York 12238, (518) 474-0453.
Hourly Wage (Temporary/Seasonal) Positions
The information will be maintained by the Regional Director (or his or her designee) in the region(s) where you are
applying for employment.
