Application | Family Choice of New York

Family Choice of New York Employment Application

It is the policy of Family Choice of New York to check an employee’s Department of Motor Vehicle’s driving record upon hire and on an annual basis. An individual will not be eligible for hire or continued employment if they:

Have had more than three (3) moving violations or more than one chargeable accident in the past thirty-six (36) months.
Have had a major conviction (driving under the influence of alcohol or drugs) within the past seven (7) years.

To Apply:

Please fill out the form below or download the application and email it to contact@familychoiceny.com

Name (First & Last)

required

Home Phone

Cell Phone

required

Are you under 18 yrs. of age?

yes

required

Email Address

Position applied for:

required

Are you legally eligible for U.S. employment?

yes

required

Availability:

required

Salary Expected

required

Have you ever been discharged or asked to resign from a job?

yes

required

Do you possess a valid driver’s license?

yes

required

Has your driver’s license ever been suspended or revoked?

yes

required

Education

Education: Highest Grade

required

Education: School Name/City/State

Education: Major/Classes Completed

Education: Did You Graduate or Receive a diploma/Degree

required

Skills

Computer software/applications you have used:

Proficient in Software

Typing WPM

10 key by touch?

Foreign Languages Spoken:

Special skills or training:

Previous Employment

Previous Employment: Company Name

required

Address:

Telephone:

Dates of Employment

Supervisor's Name

Job Title/Duties

Reason for leaving:

Previous Employment: Company Name

Address:

Telephone:

Dates of Employment:

Supervisor's Name

Job Title/Duties

Reason for leaving:

Previous Employment: Company Name

Address:

Telephone:

Dates of Employment:

Supervisor's Name

Job Title/Duties

Reason for leaving:

Previous Employment: Company Name

Telephone:

Address:

Dates of Employment:

Supervisor's Name

Job Title/Duties

Reason for leaving:

Have you been or are you excluded from participation in Medicare/Medicaid/New York State Medicaid or any other state or federally funded health care programs?

yes

Family Choice of New York will not hire or continue employment of those individuals who are currently excluded or debarred from any state or federally funded health care program participation.

Can you meet the attendance requirements of the job?

yes

required

Have you ever had a license to provide health care revoked limited, modified, suspended?

yes

required

Please list any friends or family members currently employed by Family Choice of New York:

PLEASE READ

The facts set forth in my application for employment are true and complete. I understand that if employed, false statements or omissions on this application will usually result in termination of employment. I understand that an offer of employment is contingent upon satisfactorily passing a pre-employment background check and drug screen, and satisfactory proof of lawful employment status as set forth in the Immigration Reform and Control Act. Permission is hereby given to the Company to perform a social security verification and investigate previous employment, educational background, references, criminal and civil history, motor vehicle and driver’s license records, and any other public record information on file in local, state, or federal agencies. I release the Company and former employers from any liability resulting from any lawful information provided which may result in withdrawal of an employment offer or termination. I also understand that I am not eligible for employment with Family Choice of New York if I am at any time, subject to exclusion from participating in any federally funded health care program. I understand that the Company has a policy prohibiting conflicts of interest or improper use of proprietary information which prohibits any release or use of Company property that would interfere with the business interests or operations of the Company. I understand that employment with the Company is at will and may be terminated at any time by either the Company or myself with or without cause.

Applicant Signature

By typing in your name you are verifying the information is accurate.