Application for Employment with AIM Services, Inc.

Step 1 of 2: Submit

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.

Date of Application *

Position(s) Applied For * Referral Source * If referred by an AIM Employee, please list their full name. If referred by a Self-Direction Individual, please list their full name.

Your Information

Full Name * Social Security Number * Address Line 1 * Address Line 2 City * State * ZIP * Telephone (Primary) * Telephone (Secondary) Email * If employed and you are under 18, can you furnish a work permit? * Have you filed an application here before? * If Yes, Give Date

Have you ever been employed here before? * If Yes, Give Date

Are you employed now? * May we contact your present employer? (This may be required prior to any 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 for work? *

Select the position type(s) you are applying for. (Select all that apply). Full Time Part Time Per Diem Temporary Overnights

Can you travel if job requires? * Have you EVER been convicted of a misdemeanor, felony, or other crime (other than a minor traffic infraction) in any jurisdiction? * If Yes, describe in detail (including year).

(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).

Are there any pending criminal charges, against you? * If Yes, describe in detail. 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 & drug related) * If Yes, describe in detail (include dates of occurrences).

"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."

Education

Select the highest level of education completed. * Diploma/Degree Course Study Detail any additional training or certificates related to the position you are applying for here:

Employment Experience

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

Upload Your Resume Here

Position 1 Details

Employer Job Title Work Performed Employment Start Date

Employment End Date

Supervisor Name Employer Telephone Employer Address Reason for Leaving Explain Any Gap in Time Between Position 1 and Position 2

Position 2 Details

Employer Job Title Work Performed Employment Start Date

Employment End Date

Supervisor Name Employer Telephone Employer Address Reason for Leaving Explain Any Gap in Time Between Position 2 and Position 3

Position 3 Details

Job Title Employer Work Performed Employment Start Date

Employment End Date

Supervisor Name Employer Telephone Employer Address Reason for Leaving Explain Any Gap in Time Between Position 3 and Position 4

Position 4 Details

Job Title Employer Work Performed Employment Start Date

Employment End Date

Supervisor Name Employer Telephone Employer Address Reason for Leaving

If you have additional positions you would like to submit, please upload your resume above.

Other Related History

Please list below the name, address, phone number, and dates of any prior or current experience as an employee, volunteer or provider with the New York State Office for People With Developmental Disabilities (`OPWDD"), any other state agency or any other human services provider.
Also, list any prior or current experience you have in work relevant to the position for which you are applying, including child caring experience. Employment listed above under Employment History need not be repeated.

Related History 1

Name Address Telephone Start Date

End Date

Position/Duties

Related History 2

Name Address Telephone Start Date

End Date

Position/Duties

Personal References

Please list three (3) Personal References who are not related to you, and who are not previous employers.

Reference 1

Name * Address Telephone *

Reference 2

Name * Address Telephone *

Reference 3

Name * Address Telephone *

Applicant's Statement

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Signature of Applicant *

Date: Wednesday, 16 January 2019 (EST)

Name:

Type your name to sign this document:

Typing name is equivalent to a handwritten signature

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

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