(List all educational institutions attended)
(Personal - not to include relatives - Required)
(Please begin with present or most recent employer - up to three.)
We may contact the employers listed above unless you indicate those you do no want us to contact.
Charles T. Sitrin Health Care Center, Inc. (“Sitrin”) is a Government contractor subject to Executive Order 11246, which requires Government contractors to ensure equal employment opportunity for all persons, without regard to race, color, religion, sex or national origin, and the Vietnam Era Veterans’ Readjustment Assistance Act of 1974 ("VEVRAA"), as amended by the Jobs for Veterans Act of 2002, which prohibits discrimination against protected veterans and requires Government contractors to take affirmative action to employ and advance in employment qualified disabled veterans, recently separated veterans, active duty wartime or campaign badge veterans, and Armed Forces service medal veterans.
As part of Sitrin’s affirmative action efforts, we request your cooperation in completing this voluntary identification form which allows us to comply with government requirements for record keeping and periodic reporting of this data. The information you provide will be treated confidential and will be used only in accordance with government reporting requirements. Failure to provide the information requested will not subject you to adverse consideration for the position for which you have applied.
Please indicate your ethnicity/race by selecting one or more options under Ethnicity/Race. If you believe you belong to any of these categories of protected veterans, please indicate by checking the appropriate box below. See definitions (opens in new window).
Why are you being asked to complete this form?
Because we do business with the government, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities. To help us measure how well we are doing, we are asking you to tell us if you have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will choose to fill it out. If you are applying for a job, any answer you give will be kept private and will not be used against you in any way.
If you already work for us, your answer will not be used against you in any way. Because a person may become disabled at any time, we are required to ask all of our employees to update their information every five years. You may voluntarily self-identify as having a disability on this form without fear of any punishment because you did not identify as having a disability earlier.
How do I know if I have a disability?
You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition.
Disabilities include, but are not limited to:
Reasonable Accommodation Notice
Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of reasonable accommodation include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment.
The information provided in this Application for Employment is true, correct and complete. If employed, any misstatement or omission of fact on this application may result in dismissal.
I understand that acceptance of an offer of employment does not create a contractual obligation upon the employer to continue to employee me in the future.
If you decide to engage an investigative consumer reporting agency to report on my credit and personal history, I authorize you to do so. If a report is obtained you must provide at my request, the name and address of the agency so that I may obtain from them the nature and substance of the information contained in the report.
If I am considered for a position which requires operation of a vehicle leased or owned by Sitrin, I consent to a review of my Department of Motor Vehicles driving record.
If I am considered for a position in the Rehabilitation Department as a direct care provider or in the Child Care Center, I consent to a review by the NYS Child Abuse Registry.
I understand that all applicants considered for employment with Sitrin must be cleared through the State Nurse-Aide Registry and The OIG Registry. I consent to these reviews.
In addition, I authorize you to contact any educational institution or former employers concerning any
information you or they believe is relevant to my application for employment. I hereby release Sitrin and any educational institutions or former employers for providing, sharing or using any information they may possess concerning my background or record.
Sitrin is an affirmative action/equal opportunity employer. Women, minorities, veterans and persons with disabilities are encouraged to apply.
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