Employment Application

Applicant

Please complete entire application, even if you are submitting a resume with your application.

Glove house is an equal opportunity employer and affords equal opportunity to all applicants for all positions without regard to race, color, religion, gender, national origin, age, disability, military status, sexual orientation, genetic predisposition or carrier status, martial status, or any other status protected under local, state or federal laws.

Position Desired*

Resident Counselor II (Full-time Day/Evenings)

Resident Counselor I (Full or Part-time, overnight)

Resident Counselor per Diem (As Needed)

Social Worker

Program Manager or Assistant Program Manager

Other: (Please Specify)

Name

Address

City

State

Zip

Phone

Daytime Phone

What salary or rate of pay do you expect to receive if employed? Please give an actual dollar amount. Do not write “negotiable.”

Are you legally eligible to work in the United States? (Proof of eligibility will be required upon offer of employment)

Check all that apply: I am willing to work in*

Elmira

Bath

Owego

Waterloo

Are you over the age of 18 years?

Can you with or without reasonable accommodation perform the essential functions of this job? (If you have any question about the functions of the job, please ask the interviewer before answering this question)

Have you ever applied to Glove House before?

(If yes, please give dates.)

Have you ever worked for Glove House before?

(If yes, please give dates.)

Is anyone related to you employed by Glove House?

If yes, please give their name and relationship to you.

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

If yes, please explain.

Convictions

Have you ever been convicted of a crime?

If yes, please explain. List all convictions and dates. (Include misdemeanors and felonies. A conviction will not necessarily disqualify you.)

Have you ever been indicated in any child abuse cases?

If yes, please list all indications and dates.

Do you have a valid driver's license? (All positions may require driving.)

Have you had a valid driver’s license for at least three years?

Have you been convicted of or pled guilty to any moving violations in the past five years? Note: Driving is an important part of the job for all positions. It is important that you complete this fully and accurately. Driving records will be verified.

If yes, include ALL driving related moving violations in the last five years.

DWI or DUAL. Dates

Speeding. Dates

Running a stop light, stop sign/ignoring other device. Dates

Driving without a license, with a suspended license, aggravated unlicensed operation, etc. Dates

Illegally passing a school bus. Dates

Other: Describe

Found to be at fault or negligent in causing an accident. Dates

Availibilty

Note: Many people start here on overnight/weekend Positions. Being unwilling to work overnights/weekends greatly decreases your ability to work at Glove House.

On what date would you be available to start work? *

Days and Hours Available: Check all that apply

Type of Degree

Please list any academic honors, scholarships, offices held, etc. (Do not list any which reflect your race, color, religion, gender, national origin, age, disabilities or military status.)

Describe any specialized training, apprenticeships, licenses, certifications or skills.

Why are you a good candidate for a job at Glove House? *

Employment History

Please list all employers in the last 10 years. Begin with current or most recent employer. Do not exclude any employment you had in the last 10 years. Do not write: See Resume.”

Company Name

Name and Title of Supervisor

Address, City, State and Zip

Phone

Reason for Leaving

Starting Salary

Ending Salary

Employed From

Employed To

Describe your duties

References

PROFESSIONAL REFERENCES: Please list three persons who can provide professional references. Do not include family. Do not include friends, unless they have worked with you.

Reference 1

Name

Daytime Phone Number

Occupation

Years Known

Place of Employment

Address

Reference 2

Name

Daytime Phone Number

Occupation

Years Known

Place of Employment

Address

Reference 3

Name

Daytime Phone Number

Occupation

Years Known

Place of Employment

Address

Acknowledgement

APPLICANT ACKNOWLEDGEMENT AND AUTHORIZATION

*PLEASE READ CAREFULLY BEFORE SIGNING*

I hereby certify that all of the information provided by me in this application (or any other accompanying or required document) is correct, accurate and complete to the best of my knowledge. I understand that the falsification, misrepresentation or omission of any facts in said documents will be cause for denial of employment or immediate termination of employment regardless of the timing or circumstances of discovery.

I understand that submission of an application does not guarantee employment. I further understand that should an offer of employment be extended by GLOVE HOUSE, Inc. (hereinafter referred to as “GLOVE HOUSE”) that such employment with GLOVE HOUSE is at will, for no specific duration may be terminated by either GLOVE HOUSE or myself at any time, with or without cause or notice. I understand that none of the documents, policies procedures, actions, statements of GLOVE HOUSE or its representatives used during the employment process is deemed a contract of employment real or implied. I understand that not representative of GLOVE HOUSE except the President has the authority to enter into any agreement guaranteeing any conditions of employment or any agreement contrary to the foregoing statement and that any such agreement must be made in writing and signed by the President of GLOVE HOUSE.

In consideration for employment with GLOVE HOUSE, if employed I agree to conform to the rules, regulations, policies and procedures of GLOVE HOUSE at all times and understand that such obedience is a condition of employment. I understand that due to the nature of GLOVE HOUSE business, attendance and punctuality are considered essential requirements of every job at GLOVE HOUSE and that poor attendance or tardiness will result in disciplinary action.

I understand that if offered a position with GLOVE HOUSE, I may be required to submit to pre-employment medical examinations, drug screening and background check as a condition of employment. I understand that unsatisfactory results from, refusal to cooperate with, or any attempt to affect the results of these pre-employment tests and checks will result in withdrawal of any employment offer or termination of employment of already employed.

I hereby authorize any and all schools, former & current employers, references, motor vehicle bureaus, law enforcement agencies, courts and any others who have information about me to provide such information to GLOVE HOUSE and/or any of its representatives, agents or vendors and I release all parties involved from any and all liability for any and all damage that may result from providing such information.

I understand that this application is considered current for three months. If I wish to be considered for employment after this period I must fill out and submit a new application.

BY SIGNING BELOW I ACKNOWLEDGE THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ABOVE STATEMENTS. AN ELECTRONIC SUBMISSION IS TREATED THE SAME AS A HARD COPY SUBMISSION WITH A WRITTEN SIGNATURE.

I understand and agree to the above statements.

Signature *

Date *

Name and telephone number of person completing this form if other than applicant

Glove House is an equal opportunity employer and affords equal opportunity to all applicants for all positions without regard to race, color, religion, gender, national origin age, disability, military status, sexual orientation, genetic predisposition or carrier status, or any other status protected under local, state or federal laws.

Employment Application

Applicant

Convictions

Availibilty

Days and Hours Available: Check all that apply

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Education

High School

College

Graduate School

Vocational

Other

Employment History

References

Reference 1

Reference 2

Reference 3

Acknowledgement

APPLICANT ACKNOWLEDGEMENT AND AUTHORIZATION