Employment Application

"*" indicates required fields

Date*

Position(s) Applied For*

Are you applying for the Self Direction program?*

How did you hear about this job?*

If referred by an AIM Employee, please list their full name.

If Other, please describe.

If referred by a Self Direction Individual, please list their full name.

Your Information

Applicants are considered for all positions (and treated during any subsequent employment), without regard to race, color, religion, gender, national origin, age, disability, sexual orientation, gender identity or expression, marital status, military status, domestic violence victim status, or any other prohibited basis of discrimination, as provided under applicable state and federal law. Please be advised that you may need to provide information, statements and fingerprints according to the requirements of the Agency, and OPWDD in order for a background check to be conducted through DCJS. If applicable, you will have the right to obtain, review and seek correction of any information received in response to the criminal background check conducted by DCJS.

Name*

First Last

Social Security Number*

For initial background check.

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Email*

If you are under 18, can you furnish a work permit?

Have you filed an application here before?*

If Yes, Give Date

Are you employed now?*

May we contact your present employer?

This may be required prior to an employment offer.

Are you prevented from lawfully becoming employed by this country?*

Proof of citizenship or immigration status will be required upon employment.

On what date would you be available to start work?*

Select the position type(s) you are applying for.*

Select all that apply. Hold Ctrl button to select multiple options.

Can you travel if the job requires?*

Have you EVER been convicted of a misdemeanor, felony, or other crime (other than a minor traffic infraction) in any jurisdiction?*

A conviction is not an automatic bar from employment. Each case is considered and evaluated on its individual merits in relation to the duties and responsibilities of the position.

If Yes, describe in detail (including year).

Have you EVER been sanctioned or otherwise disciplined by, or excluded from, the New York Medicaid Program, Medicare or any other state or federal government funded program?*

If Yes, describe in detail.

Have you had a personal or employment related conviction or prior history of child abuse, neglect or mistreatment?*

If Yes, describe in detail.

Have you EVER been convicted of a motor vehicle moving violation, OR had any suspension, revocation, or accidents involving harm to people or property?*

Not limited to alcohol and drug related.

If yes, describe in detail (including dates of occurrences).

Education

Select the highest level of education completed.*

Diploma/Degree Course Study

Describe in detail any additional training or certificates related to the position you are applying for.

Employment Experience

Upload your resume or complete your employment experience below. Start with your most recent employment. Include military service assignments and positions related volunteer activities.

Do you have employment experience?*

Do you have a resume to upload?*

If not, please complete your employment experience below.

Upload Your Resume*

Accepted file types: pdf, doc, docx, Max. file size: 25 MB.

Most Recent Employer*

Most Recent Employer Address*

Street Address City State ZIP Code

Employment Start Date*

Employment End Date

Leave blank if currently employed.

Currently Employed

Check if you are currently employed.

Job Title*

Duties/Work Performed*

Supervisor's Name*

Supervisor's Phone*

Reason for Leaving*

Brief description.

Do you have more employment experience to add?

Previous Employer

Previous Employer Address

Street Address City State ZIP Code

Employment Start Date

Employment End Date

Job Title

Duties/Work Performed

Supervisor's Name

Supervisor's Phone

Reason for Leaving

Brief description.

Do you have more employment experience to add?

2nd Previous Employer

2nd Previous Employer Address

Street Address City State ZIP Code

Employment Start Date

Employment End Date

Job Title

Duties/Work Performed

Supervisor's Name

Supervisor's Phone

Reason for Leaving

Brief description.

Do you have more employment experience to add?

3rd Previous Employer

3rd Previous Employer Address

Street Address City State ZIP Code

Employment Start Date

Employment End Date

Job Title

Duties/Work Performed

Supervisor's Name

Supervisor's Phone

Reason for Leaving

Brief description.

Personal References

Please list three personal references. Personal references cannot be a relative or significant other.

1st Personal Reference's Name*

1st Reference's Phone*

1st Reference's Email*

2nd Personal Reference's Name*

2nd Reference's Phone*

2nd Reference's Email*

3rd Personal Reference's Name*

3rd Reference's Phone*

3rd Reference's Email*

Applicant's Statement Consent*

I agree to the Applicant's Statement.

I certify that the information I provided on this application and any accompanying documentation, and will provide throughout the hiring process is true and complete to the best of my knowledge. The company may investigate all statements contained in this application and may utilize social media searches to do so. In the event of employment, I understand that false, incomplete or misleading information given in my application, during the interview(s), or at any other time, is grounds for and may result in immediate discharge regardless of the timing or circumstances of discovery.

It is my understanding that AIM Services, Inc. will make a thorough investigation of my work history and may verify all data given in my application of employment. I authorize the giving and receiving of any information requested by AIM Services and release from liability any person giving or receiving information.

I further understand that, should an offer of employment be extended, that employment will be “at will”, for no specified duration and may be terminated by myself or AIM at any time, with or without cause. I understand that neither this application, any statements made by any AIM representatives, nor any offer of employment from AIM constitutes an employment contract. I also understand that no representative of AIM has the authority to enter into an employment contract, guarantee employment for a specified period, or modify any of the foregoing, other than in a written document signed by the Executive Director.

I understand, also, that I am required to abide by all rules, policies and procedures, and regulations of the employer, and that any employment offer may be contingent on acceptable references, physicals, testing, and criminal background checks.

AIM Services, Inc. is an Equal Opportunity Employer and has strict policies against discrimination in the application and course of employment.

Electronic Signature*

I Accept

By selecting the "I Accept" button, you are signing this Agreement electronically. You agree your electronic
signature is the legal equivalent of your manual/handwritten signature on this Agreement.

By selecting the "I Accept" and/or providing your electronic signature you certify that the information you provided on this application and any accompanying documentation, and will provide throughout the hiring process is true and complete to the best of your knowledge.

By selecting "I Accept" using any device, means or action, you consent to the legally binding terms and conditions of this Agreement. By selecting "I Accept" you understand that AIM Services, Inc. will make a thorough investigation of your work history and may verify all data given in my application of employment.

By selecting "I Accept" you authorize the giving and receiving of any information requested by AIM Services and release from liability any person giving or receiving information.

You further agree that your signature on this document (hereafter referred to as your "E-Signature") is as valid as if you signed the document in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature, and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature or any resulting agreement between you and AIM Services, Inc. You are also confirming that you are the person authorized to enter into this Agreement.

Electronic Signature*

Type your electronic signature in the field above.