Office of Children & Family Services

OCFS-0001 (Rev. 06/2014) Page 1

NEW YORK STATE

OFFICE OF CHILDREN & FAMILY SERVICES

APPLICATION FOR EMPLOYMENT

Existing laws prohibit discrimination in selection because of race, creed, color, religion, national origin, sexual orientation, age, sex, military status, disability, predisposing genetic characteristics, marital status, arrest or criminal conviction record. If a reasonable accommodation is required, contact the Director of the Office of Equal Opportunity and Diversity Development at (518) 473-7936.

A. PERSONAL INFORMATION

LAST NAME: / FIRST NAME: / MI: / SOCIAL SECURITY NUMBER:
STREET ADDRESS: / HOMEPHONE NUMBER:
MAILING ADDRESS:
CITY: / STATE: / ZIP CODE: / ADDITIONAL PHONE NUMBER:

B. POSITION(S) DESIRED (If Known)

JOB TITLE: / DATE AVAILABLE: / FullTime
Part Time / ARE YOU ON A CIVIL SERVICE LIST FOR THIS POSITION?
Yes No
Employment Opportunity Announcement (EOA) number, if applicable: / .
How did you learn of this vacancy? OCFS Website StateJobsNY Coworker/friend Other (please specify):

C. EDUCATIONAL INFORMATION

*HIGH SCHOOL:

/ LOCATION: / MAJOR/MINOR: / DID YOU GRADUATE?
Yes No / DEGREE:

COLLEGE UNIVERSITY, PROFESSIONAL OR TECHNICAL SCHOOL:

/ LOCATION: / MAJOR/MINOR: / DID YOU GRADUATE?
Yes No / DEGREE:

OTHER SCHOOLS OR GRADUATE SCHOOLS:

/ LOCATION: / MAJOR/MINOR: / DID YOU GRADUATE?
Yes No / DEGREE:
*NOTE: If you did not complete high school, please indicate last grade/school attended in the degree column. If applicable, do you have a New York State High School Equivalency Diploma? Yes No

D. LICENSE

If a license, certificate, registration, or other authorization to practice a trade or profession is required for the position for which you are applying, complete the following questions.

For teacher certification, please indicate specialty and whether certification is Initial, Provisional, Permanent or Professional.

NAME OF TRADE OR PROFESSIONAL LICENSE: / ISSUED BY: / DATE ISSUED: / DATE EXPIRES:

E. LICENSE(S) FOR WHICH YOU ARE ELIGIBLE:

Have you ever been found guilty of unprofessional conduct, professional misconduct, or negligence in any profession? / Yes (Explain under “K. Additional Remarks” ) / No
Are charges now pending against you for unprofessional conduct, or negligence in any profession? / Yes (Explain under “K. Additional Remarks” ) / No
Have you ever surrendered any license in lieu of disciplinary procedures? / Yes (Explain under “K. Additional Remarks” ) / No

OCFS-0001 (Rev. 06/2014) Page 2

F. ADDITIONAL INFORMATION-(Answer all questions)

1. Are you 18 years of age or older? / Yes No
2. Do you possess a current, valid Driver’s License? / Yes No
DMV ID No.: / Issuing State: / Expiration Date:
3. Are you a citizen of the United States? / Yes No
If no, do you have the legal right to accept employment in the United States? / Yes No
Proof of Employment Authorization will be required upon employment.

1. Have you ever been employed by New York State?

If Yes, From: To: Agency: / Yes No

1. Have you ever been employed by the Office of Children and Family Services?

If Yes, From: To: Job Title: / Yes No

1. Are you an exempt volunteer firefighter?

/ Yes No
7. Are you a member of the NYS Retirement System? / Yes No

1. Have you ever resigned from employment in lieu of disciplinary action or termination?

If Yes, explain in Section K (Additional Remarks). / Yes No
9. Have you ever been or are you currently the subject of an indicated child abuse or maltreatment
report on file with the New York Statewide Central Register of Child Abuse and Maltreatment?
If Yes, explain in Section K (Additional Remarks). / Yes No
NOTE: An affirmative answer to the above questions does not automatically bar a candidate from employment. Each case is determined on its own merit.

G. CRIMINAL HISTORY-(Please answer all questions in this section.)

Before you proceed to answer the questions under Section “G” of this application, please be advised that by answering “No”, you are stating that there are no arrests or criminal accusations pending against you in New York State or in any other jurisdiction, and that you have never been convicted of a felony, misdemeanor or violation in New York State or in any other jurisdiction. You should answer “No” if (i) your conviction (felony, misdemeanor or violation) was sealed by a court; or (ii) the criminal action or proceeding was terminated in your favor, e.g., was dismissed, you received an Adjournment in Contemplation of Dismissal and the adjournment period has elapsed, or you were acquitted; or (iii) the proceeding on the criminal offense resulted in a youthful offender adjudication or juvenile delinquency finding which has been sealed/expunged pursuant to the Family Court Act; or (iv) after completing a treatment program, your plea to a felony or a misdemeanor was withdrawn and you were resentenced to a violation which was sealed by the court or the completion of the program resulted in a dismissal of all charges by the court.

Please be further advised that (i) your failure to disclose a prior conviction in accordance with the guidelines set forth in Section “G” of this application may result in the denial of employment based on the falsification of this employment application; (ii) your disclosure of a prior criminal conviction or, while in the military service, of a conviction by court-martial, may or may not preclude employment, depending on the nature of the offense, its relationship to the position sought, and other factors that must be considered before employment may be lawfully denied based on a prior conviction and in accordance with Human Rights Law Sections 296.15 and 296.16; and (iii) a national criminal records check will be conducted, in addition to the New York State criminal records checks. If there is a time delay, you may be appointed contingent upon the national clearance being received. Note, however, that should the national clearance establish that you have pending arrest(s) or conviction(s) in any state, you may be removed from the payroll pending resolution. If a waiver has been requested for you to begin working prior to conclusion of the screening process, you must successfully complete the entire screening process in order to be retained in the position.

If you are unsure of any response provided below, you may include a written explanation in Section K (Additional Remarks) of this application.

Do you have an arrest or criminal accusation currently pending against you? If yes, please describe the underlying circumstances and progress of any pending arrests or criminal accusations in Section K(Additional Remarks) of thisapplication. (If a prior arrest or criminal accusation resulted in a conviction, you mayneed to disclose this information in response to the following question.) / Yes No
Have you ever been convicted of a criminal offense or, while in the military service, of an offense by court-martial, including any felonies, misdemeanors, or violations?
If yes, then please provide a description of the conviction(s) in Section K (Additional Remarks) of this application. / Yes No

OCFS-0001 (Rev. 06/2014) Page 3

Have you ever been granted a Certificate of Relief from Disabilities or a Certificate of Good Conduct?
If yes, please provide a description of the certificate(s) received in Section K (Additional Remarks) of this application. / Yes No

H. MILITARY INFORMATION

Have you ever served in the Armed Forces of the United States? / Yes No / Branch and Rank:
From: / To:
Are you claiming Veteran’s Credits for seniority purposes? / Yes No / If you answer “Yes” and you are hired, you will be required to furnish a copy of your DD214.
Did you receive an honorable discharge? / Yes No / A “No” answer is not anautomatic bar to employment.
Each response will be reviewed on an individual basis in relation to ability to perform job duties.

I. EMPLOYMENT HISTORY

List all employment within the past ten years. Please indicate present employer first. If you are a current and/or former State employee, please list your exact Civil Service title.

FROM (MO/YR) / NAME OF PRESENT EMPLOYER / TITLE
TO (MO/YR) / EMPLOYER’S ADDRESS / DUTIES
SALARY / NAME OF SUPERVISOR / REASON FOR LEAVING / MAY WE CONTACT?
Yes No
FROM (MO/YR) / NAME OF PREVIOUS EMPLOYER / TITLE
TO (MO/YR) / EMPLOYER’S ADDRESS / DUTIES
SALARY / NAME OF SUPERVISOR / REASON FOR LEAVING / MAY WE CONTACT?
Yes No
FROM (MO/YR) / NAME OF PREVIOUS EMPLOYER / TITLE
TO (MO/YR) / EMPLOYER’S ADDRESS / DUTIES
SALARY / NAME OF SUPERVISOR / REASON FOR LEAVING / MAY WE CONTACT?
Yes No
FROM (MO/YR) / NAME OF PREVIOUS EMPLOYER / TITLE
TO (MO/YR) / EMPLOYER’S ADDRESS / DUTIES
SALARY / NAME OF SUPERVISOR / REASON FOR LEAVING / MAY WE CONTACT?
Yes No
FROM (MO/YR) / NAME OF PREVIOUS EMPLOYER / TITLE
TO (MO/YR) / EMPLOYER’S ADDRESS / DUTIES
SALARY / NAME OF SUPERVISOR / REASON FOR LEAVING / MAY WE CONTACT?
Yes No

J. PROFESSIONAL REFERENCES (List three) If needed, continue under Section K(Additional Remarks).

NAME / RELATIONSHIP / PHONE NUMBER
ADDRESS
NAME / RELATIONSHIP / PHONE NUMBER
ADDRESS
NAME / RELATIONSHIP / PHONE NUMBER
ADDRESS

OCFS-0001 (Rev. 06/2014) Page 4

K. ADDITIONAL REMARKS

I swear and affirm that the statements on this application and any attached papers are correct to the best of my knowledge. I also understand that falsification of this application may result in my dismissal if I am accepted for employment. I agree to be fingerprinted, to obtain clearance through the NYS Child Abuse Registry, and to pay the appropriate fees required, whether or not I am hired. If I am accepted for employment, I agree to take any physical examination that may be required by the Office of Children and Family Services if it is a condition of employment.I have read and understand the entire contents of this application.

Signature: / X / Date: