About Administrative Team Mission, Vision, Values History Board Members & Staff Corporate Compliance & Quality Assurance Job Opportunities Employee Benefits Online Application Online Application Personal InformationName* First Middle Last Present Address* Street Address City State / Province / Region ZIP / Postal Code Home Telephone Number*Cell Phone NumberEmail* What types of positions are you interested in? Salary/Wage Desired: Are you legally eligible for employment in the USA?*NoYesWould you Work:Full-timePart-timeDaysEveningsWeekendsOvernightsAre you 18 years of age or older?*NoYesDo you know anyone who works for CWI?NoYesIf Yes, indicate whom. How did you hear about CWI? Have you ever been employed by CWI?*NoYesIf Yes, indicate when and why you left. Have you ever been convicted of a misdemeanor or a felony in any jurisdiction or do you have any pending criminal charges against you?*NoYesIf Yes, indicate the date and nature of conviction or pending charge. Educational BackgroundHigh SchoolName & Address of SchoolCourse of StudyDid you Graduate?NoYesDegree/Credits EarnedCollegeName & Address of SchoolCourse of StudyDid you Graduate?NoYesDegree/Credits EarnedCollege/OtherName & Address of SchoolCourse of StudyDid you Graduate?NoYesDegree/Credits EarnedAwards or CertificatesAwards or CertificatesEmployment HistoryList below last three employers starting with most current or recent employer. Identify any prior or current experience as an employee, volunteer or certified provider with OPWDD, any other state agency, or any other provider of human services. Indicate an prior or current experience in direct care relevant to the position applying for.Job 1Employer: Address: Street Address City State / Province / Region ZIP / Postal Code Telephone:Immediate Supervisor: Start Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Title and Duties:Hours/Week: Reason for Leaving:Job 2Company: Address: Street Address City State / Province / Region ZIP / Postal Code Telephone:Immediate Supervisor: Start Date: MM slash DD slash YYYY End Date: MM slash DD slash YYYY Title and Duties:Hours/Week: Reason for Leaving:Job 3Company: Address: Street Address City State / Province / Region ZIP / Postal Code Telephone:Immediate Supervisor: Start Date: MM slash DD slash YYYY End Date: MM slash DD slash YYYY Title and DutiesHours/Week: Reason for Leaving:I give permission for CWI to contact my former employer(s).NoYesI give permission for CWI to contact my current employerNoYesReferencesPlease provide the names of three work related/professional references who we may contact.Professional Reference 1Name: Title: Telephone:Company: Address: Professional Reference 2Name: Title: Telephone:Company: Address: Professional Reference 3Name: Title: Telephone:Company: Address: Is additional information relative to a change of name, assumed name or nickname necessary to enable to check references for education or employment verification?* Yes No If yes, please explain:*Per NYS OMRDD Regulation Part 681: Have you ever been the subject of an indicated report of child abuse or maltreatment?* Yes No Do you have a conviction or a history of client or child abuse, neglect or mistreatment?* Yes No I attest that the information that I have provided on my Application For Employment is true, correct, and complete to the best of my knowledge. I acknowledge that any false or misleading information or significant omission may disqualify me from further consideration for employment, or be the grounds for dismissal. I further understand that acceptance of an offer of employment does not create a contractual obligation upon CWI to continue to employ me in the future. If hired, I agree to abide by all of the company rules and regulations, and understand that my employment may be terminated at any time at the option of the agency or myself. I understand that an offer of employment is conditional based on background checks relative to the position I am being offered. I authorize CWI to investigate and obtain copies of records related to my employment history and education, and any additional information provided in connection with this application. I authorize all former employers and educational institutions to provide job-related information to CWI, and I release them and CWI from all liability or responsibility for supplying or requesting such information as part of an investigation. Applicant Signature*Date* MM slash DD slash YYYY CommentsThis field is for validation purposes and should be left unchanged.