Application for Employment
Section I
Referred by
Relatives
Do any relatives work here?
Relationship
Section II
Last Name
First Name
Middle Name
Street Address or PO Box
City
State
Zip Code
Phone
Best Time To Reach You
Are your work records under another name/names?
If yes, specify
Have you previously filed an application with SullivanArc?
Have you previously been employed by SullivanArc?
Are you 18 or over?
Schedule Desired:
(check all that apply):
Are you currently employed?
If yes, may we contact your present employer?
Are you legally eligible for employment in the U.S.A.?
Have you ever been convicted of a crime?
Description
Date
Do you have any pending criminal charges?
Description of Pending Charges
Do you have a history of substantiated abuse on file in the OPWDD, OMH or DOH system? If yes, please explain
Section III
License
Please be advised that employment offers will be conditional for those positions that require driving. No firm offer will be made until verification of your license and driving history has been completed. Do you currently have a valid NYS or Out of State driver's license?
Specify any Moving violation within the last three (3) years and any suspensions, revocations, DWI/DUAI infractions, convictions, or any other vehicular accidents involving injury to persons or property.

Section IV

Education
Did You Graduate?
Did You Graduate

Section V

Employment Experience
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Phone Number
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Employment Experience
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Employment Experience
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List any other experiences, skills, qualifications, professional licenses you believe will be beneficial in considering your application.

Section VII

Personal References
List four names, NOT former employers or relatives (or choose the upload option below)
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First Name
Last Name
Country
Address Line 1
City
State
Postal Code
Phone Number
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First Name
Last Name
Country
Address Line 1
City
State
Postal Code
Phone Number
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First Name
Last Name
Country
Address Line 1
City
State
Postal Code
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First Name
Last Name
Country
Address Line 1
City
State
Postal Code
Phone Number
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Applicant Authorizations

Please read and sign

I affirm that the facts set forth in my application are true and complete. I understand that if employed, any omission of facts or false statement on this application may result in my dismissal. I further understand that this application is not, and is not intended to be, a contract of employment nor does this application obligate the employer in any way if the employer decides to employ me. I understand and agree that my employment is at-will and can be terminated by either party without notice, at any time, for any reason or no reason. No one other than an officer of the agency has any authority to enter into any agreement for any employment for any specific period of time or to make any agreement contrary to the foregoing and then only in a written signed statement by an officer. 

I authorize SullivanArc to make inquiries and investigations of my person, employment history and other related matters as may be necessary in arriving at the employment decision. I hereby release employers, schools and persons from all liability in responding to inquiries in connection with my application. 

I also understand that I am required to abide by all rules and regulations of the agency and that I will be required to provide proof of citizenship or work permit at time of employment. 

I understand that any offer of employment is conditional pending the results of my Staff Exclusion List Check, Criminal Background Check, MHL 16.34, Child Abuse Registry Check and Driving Abstract, PPD and Employ Smart (Physical Assessment).

I agree with the statement above

The Arc does not discriminate in employment on the basis of race, color, religion, sex (including pregnancy and gender identity), national origin, political affiliation, sexual orientation, marital status, disability, genetic information, age, membership in an employee organization, retaliation, parental status, military service, or other non-merit factor.”

  • SullivanArc is a Chapter of