Application - Family Choice of New York

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(716) 668-7051 or (800) 506-7051
contact@FamilyChoiceNY.com

Family Choice New York

3332 Walden Ave #110
Depew, NY 14043

Contact:
Phone: (716) 668-7051
Toll-Free: (800) 506-7051
Email: contact@FamilyChoiceNY.com

Hours:
Monday – Friday
8:30am-5:00pm EST

Family Choice of New York Employment Application

To Apply:

By typing my name below, I agree I am the individual reflected and agree to the terms et fourth above.

Please enable JavaScript in your browser to complete this form.

MY INFORMATION

Name (First & Last) *

required

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Cell Phone *

required

Email Address *

Position applied for: *

How did you hear about us? *

Are you under 18 yrs. of age? *

YES
NO

Are you legally eligible for U.S. employment? *

YES
NO

Availability *

Days
Evenings
Nights
Weekends

Salary Expected *

Per Hour/Year? *

Per Hour
Per Year

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

YES
NO

Do you possess a valid driver’s license? *

YES
NO

EDUCATION

Check highest grade completed *

HS/GED
Associates
Bachelors
Masters
Doctorate
Other

Other

Educational Information

School Name/City/States

Major/Classes Completed

Did you Graduate?

YES
NO

Diploma/Degree

SKILLS

Home Did Supervisor’s

Computer software/applications you have used

Foreign Languages Spoken

Typing

Special Skills or training

EMPLOYMENT

Employment Information

Company Name *

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Dates of Employment *

to *

Place in a Date, or type in 'I currently work here'.

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
NO

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 pursuant to applicable law.

Can you meet the attendance requirements of the job? *

YES
NO

Have you ever had a license to provide healthcare revoked limited, modified, suspended? *

YES
NO

Have you ever had privileges at any health facility/clinic or hospital suspended, revoked, or not renewed, or is your position in any other health facility/clinic or hospital under review? *

YES
NO

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

PLEASE READ *

1. 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 employment is contingent upon satisfactorily passing a pre-employment background check, providing satisfactory proof of lawful employment status as set forth in the Immigration Reform and Control Act and in certain instances passing a drug screen consistent with applicable law. 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.

Date *

(716) 668-7051
(800) 506-7051
contact@FamilyChoiceNY.com

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