James Square Health and Rehabilitation Centre :: Syracuse, NY :: Job Application/

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Application For Employment.
Required fields are indicated with an *

James Square is an Equal Opportunity and Affirmative Action Employer. NYS and federal law prohibit discrimination based on age, race, creed, color, sex, national origin, disability, marital status, sexual orientation, genetic information, or protected veterans. Our application forms are designed to obtain an applicant's skill, knowledge, and abilities on specific job requirements.
I. Identifying Information
*Position applying for:
2nd position applying for:
3rd position applying for:
4th position applying for:
Select Job Type Preference:
Shift Preference
*First Name:
*Middle Name:
*Last Name:
*Street:
*City:
*State:
*Zip Code:
*#1 Phone:
315-XXX-XXXX
#2 Phone:
315-XXX-XXXX
#3 Phone:
315-XXX-XXXX
*Your email address:
How were you referred
to James Square?:
*Are you 18 years or over?
If under 18, do you have working papers?
*Are you a citizen of the U.S.?:
If no, do you have a legal right to remain and work in the United States?:
Alien Registration #:
*Have you ever been convicted
of a crime?:
If yes, please explain:
Have you ever been employed using a different name?:
Do you have a Professional Certification/License/Registration from NYS?:
Have you ever held a Professional Certification/License/Registration from another state?:
If yes, which one?
Has your professional license ever been suspended, revoked or surrendered?
If Yes, please give date and explanation:
II. Previous Employment
Have you ever been employed at James Square in the past?
If yes, in what department did you work and when?
III. Formal Education

List your formal schooling, including academic, vocational, professional, and other relevant training courses including dates attended and graduation dates.
High School:
Grade Completed:
Diploma?:
Technical/Vocational School:
Major:
Certificate?:
College Name:
College Major:
Degree?:
Other:
Other:
IV. Employment History
#1
Beginning with your most recent employment, please list the information requested below and describe briefly the job duties.
Employer:
Phone #:
Address:
Position Held:
Immediate Supervisor:
Dates Employed:
Salary Range:
Job Duties:
Reason for Leaving:
#2
Employer:
Phone #:
Address:
Position Held:
Immediate Supervisor:
Dates Employed:
Salary Range:
Job Duties:
Reason for Leaving:
#3
Employer:
Phone #:
Address:
Position Held:
Immediate Supervisor:
Dates Employed:
Salary Range:
Job Duties:
Reason for Leaving:
#4
Employer:
Phone #:
Address:
Position Held:
Immediate Supervisor:
Dates Employed:
Salary Range:
Job Duties:
Reason for Leaving:
V.
I hereby certify that all statements I have made in connection with my application for employment are true, and that I have not withheld any pertinent information. I understand that any misrepresentation or purposeful omission of facts made in connection with my application for employment are reasons to disqualify me from further consideration and can be grounds for termination if I am hired. I hereby authorize any person or persons to give James Square's representatives any information about me, and release them from any liability for doing so. I also understand that my application will be valid for 6 month and will not be considered after 6 month has expired.
*I Agree:
Resume
Resume Upload formats are limited to .pdf, .doc, .docx, .txt., .rtf formated files.
Voluntary EEO Identification
As part of James Square's equal employment opportunity and affirmative action obligation, 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 applicant data. The information you provide will be treated as confidential and will be used only in accordance with required reporting obligations. Failure to provide the information requested will not subject you to adverse consideration for employment.
Please access the Applicant Voluntary EEO Identification form below. You can fax your completed form to:
315-422-2632
or mail to:
James Square Human Resource Dept
918 James Street
Syracuse, NY 13203
Download EEO form:
Voluntary EEO Application