Application for Employment with AIM Services, Inc.

Your Information

Full LEGAL Name * Preferred Name Social Security Number * Address Line 1 * Address Line 2 City * State * Select an option:AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDist of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP * Telephone (Primary) * Telephone (Secondary) Email * If employed and you are under 18, can you furnish a work permit? * Select an option:YesNoN/A Have you filed an application here before? * Select an option:YesNo If Yes, Give Date Have you ever been employed here before? * Select an option:YesNo If Yes, Give Date Are you employed now? * Select an option:YesNo May we contact your present employer? (This may be required prior to any employment offer). * Select an option:YesNo Are you prevented from lawfully becoming employed by this country? (Proof of citizenship or immigration status will be required upon employment). * Select an option:YesNo 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? * Select an option:YesNo Have you EVER been convicted of a misdemeanor, felony, or other crime (other than a minor traffic infraction) in any jurisdiction? * Select an option:YesNo 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? * Select an option:YesNo 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? * Select an option:YesNo If Yes, describe in detail. Have you had a personal or employment related conviction or prior history of child abuse, neglect or mistreatment? * Select an option:YesNo 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) * Select an option:YesNo 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."

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Education

Select the highest level of education completed. * Select an option:Elementary (up to 8th grade)Some High SchoolHigh School DiplomaSome CollegeAssociate DegreeBachelor DegreeMaster DegreeDoctoral Degree Diploma/Degree Course Study Detail any additional training or certificates related to the position you are applying for here:

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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 * Email Address Telephone *

Reference 2

Name * Email Address Telephone *

Reference 3

Name * Email Address Telephone *

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Applicant's Statement

Signature of Applicant *

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