Comments






Secure Application for Employment
HR7940 Rev 07/02
Human Resources Department
6th Avenue and Franklin Street
Red Cloud, Nebraska 68970
It is the policy of this facility to provide equal opportunity to persons regardless of race, religion,
age, gender, disability or any other classification in accordance with federal, state and local        
statutes, regulations and ordinances.                                                                                       
http://www.websterhospital.org
email:  mlolson@websterhospital.org
Date First Viewed
This application can be active as long as legally required.
Last Name, First Name MI
 
Are You At Least 18 Years Old?

Social Security Number (secure)

Home Phone And Cell Phone

Present Address

Present City

Present State

Present Zip Code

E-Mail Address

Previous Address

Previous City

Previous State

Previous Zip

Current Open Position(s) for Which You Are Applying
Position #1:
Position #2:
Position #3:

Type of Position
Full Time
PRN
Part Time
Shift

Day
Night

Salary Requirement
$
Are You Willing To Travel?


Are You Willing To Relocate?


Do you have adequate means of transportation to get to work on time each day and when called in on short notice during normal working hours?

If overtime work is required periodically, does this pose a problem for you?

Date Available For Work

Are You Legally Authorized to Work in the U.S.?

Have you ever worked for WCCH?
Please provide position and dates of employment.
Are you related to another facility employee?

How did you learn about this position?
State Employment
       Commission

Internet
Agency
Ad
Job Listing
School
Current Employee
Job Line
Other:

Are you able to perform the essential, job related functions of the position for which you are applying with or without accommodations?
Describe any accommodations necessary:

Have you been convicted of a crime and/or released from confinement following a conviction for any criminal offense? Arrests or charges that have been expunged need not be disclosed.
If yes, give date, place and nature of each such conviction.

Are you presently charged with any violation of the law?
If yes, give date, place and nature of each such event:

Are you currently excluded from participation in any federally funded healthcare program - including Medicare and Medicaid - and are you
aware of any potential exclusion from a federally funded health program?
Educational History
Type of School
Name of School

City, State
Check Last Year
Attended in School

Degree or Certificate
High School/
GED



9   10   11   12
Graduated/GED?

College


1    2     3    4
Graduated?

College


1   2    3     4
Graduated?

Graduate
School


1    2     3    4
Graduated?

Other


1    2    3    4
Graduated?

Other


1    2    3    4
Graduated?


List any professional licenses, registration or certification you possess
(Include Driver's License, if applicable)
Include Type, State Issued, Expiration Date and Number
Indicate if any licenses have been revoked, suspended or placed on probation.
Also indicate if you are ineligible to become licensed or certified in your field. Please explain.

Clerical or other skills applicable to the position for which you are applying
Typing  (WPM)              PBX
Proficient in Software: 
Business machines and/or equipment you can operate:
      
Other 


Work History Application for Employment
HR7940 Rev 07/02





From
Mo.

Yr.

To
Mo.

Yr.

Company

Phone No.

Immediate Supervisor

Salary
$
Address

May we contact them?

Name while employed

Job Title

Type of Position:
# Hrs /Week:
Reason for leaving

Nature of Duties






From
Mo.

Yr.

To
Mo.

Yr.

Company

Phone No.

Immediate Supervisor

Salary
$
Address

Name while employed

Job Title

Type of Position:
# Hrs/Week:
Reason for leaving

Nature of Duties







From
Mo.

Yr.

To
Mo.

Yr.

Company

Phone No.

Immediate Supervisor

Salary
$
Address

Name while employed

Job Title

Type of Position:
# Hrs/Week:
Reason for leaving

Nature of Duties







From
Mo.

Yr.

To
Mo.

Yr.

Company

Phone No.

Immediate Supervisor

Salary
$
Address

Name while employed

Job Title

Type of Position:
# Hrs/Week:
Reason for leaving

Nature of Duties

Professional References (Other than Relatives) Give references who have good knowledge of your work.
Name
Position
Address (Include City/State)
Phone - Work/Home
Number of
Years known





















Please Review and Acknowledge That You Understand The Following.
In making application for employment:
* I certify that the information in this application is true and complete for all practical purposes.  It may be verified by the facility or any affiliate.  Should a position be offered and later it is found that the information is significantly untrue, incomplete, or misrepresented, I understand and agree that the facility or its affiliates are relieved of all commitments, financial or otherwise pertinent to employment, and that I am subject to immediate discharge without recourse.

* I understand that an investigative report may be made by a consumer reporting agency to include information as to my character, general reputation, personal characteristics, and mode of living, whichever may be applicable.  If such an investigative report is made, I understand that I will receive notice that such a report has been requested, and that I will have the right to make a written request for a complete and accurate disclosure of additional information concerning the nature and scope of the investigation.


* I UNDERSTAND AND AGREE THAT ANY EMPLOYEE HANDBOOK WHICH I MAY RECEIVE WILL NOT  CONSTITUTE AN EMPLOYMENT CONTRACT, BUT  WILL BE MERELY A GRATUITOUS STATEMENT OF  FACILITY POLICIES.

*
I understand that the facility reserves the right to require its employees to submit to blood tests or urinalyses for alcohol or drug screens, or to allow inspection of bags (including purses or briefcases) or parcels brought into  or taken out of the facility.  I understand that refusal to  submit to a urinalysis or blood test, when requested to  do so, may result in termination of my employment.

* Compliance with this facility's Substance Abuse Policy is  a condition of employment.  This hospital requires that  every newly hired employee be free of alcohol or drug  abuse.  Each offer of employment is contingent upon  successfully completing a urinalysis test/screen for  alcohol and drugs in accordance with facility policy. Continued employment is also contingent upon  compliance with the hospital's Alcohol and Drug Abuse Policy.

*I UNDERSTAND AND AGREE THAT IF I AM OFFERED  EMPLOYMENT BY THE FACILITY, MY EMPLOYMENT  WILL BE FOR NO DEFINITE TERM AND THAT EITHER  I, OR THE FACILITY WILL HAVE THE RIGHT TO  TERMINATE THE EMPLOYMENT RELATIONSHIP AT  ANY TIME, WITH OR WITHOUT CAUSE, AND WITH  OR WITHOUT NOTICE,  I ALSO UNDERSTAND THAT THIS STATUS CAN ONLY BE ALTERED BY A WRITTEN CONTRACT OF EMPLOYMENT WHICH IS SPECIFIC AS TO ALL MATERIAL TERMS AND IS  SIGNED BY ME AND THE ADMINISTRATOR OF THE FACILITY.

Release:
 
I hereby authorize any prior employers to provide such  information concerning my employment with them as  may be requested, and also authorize the  Registrar/Placement Office of all educational institutions  attended to release an official copy of my transcript and,  if available, faculty appraisals.  I also authorize any  appropriate licensing board to release full information  concerning my licensure status and my licensure history.

This institution does not discriminate in hiring or any other decision on the basis of race, color, sex, citizenship, national origin, ancestry, Vietnam era veteran status, or on the basis of age or physical or mental disability unrelated to ability to perform the work required. No question on this application is intended to secure information to be used for such discrimination.

I voluntarily give this institution the right to make a thorough investigation of my past employment and activities, agree to cooperate in such investigation and release from all liability or responsibility all persons, companies or corporations supplying such information. I consent to take the physical examination, and such future physical examinations as may be required by this institution at such times and places as the institution shall designate. I understand that an offer of employment may be contingent on passing the physical examination which relates to the essential duties I would be required to perform.

I understand that my employment is at will, and that either party is free to terminate the employment relationship at any time without cause. I also understand that my employment may be terminated for any misstatement or omission of fact appearing on this application form.

If employed, I will be required to complete an Employment Verification Form (I-9), and within three days show satisfactory evidence of identity and eligibility for employment.

I agree that I will settle any and all claims, disputes or controversies arising out of or relating to my application for employment, employment or termination of employment with the employer exclusively by final and binding arbitration and before a neutral Arbitrator and in accordance with the rules and procedures for employment disputes adopted by the employer.  Such claims shall include those that could be brought in a court of law under any applicable federal, state or local statutory or common law, such as the Age Discrimination in Employment Act, Title VII of the Civil Rights Act of 1964, as amended, including the amendments of the Civil Rights Act of 1991, the Americans with Disabilities Act, the Family and Medical Leave Act, state civil rights acts, the law of contract and the law of tort.
I have read and understand
these conditions of employment.

Applicant's full name

Date Prepared






BACKGROUND CHECK DISCLOSURE

In the interest of maintaining the safety and security of our customers, employees, and property, Webster County Community Hospital (the "Company") will order a "consumer report" (a background check) on you in connection with your employment application, and if you are hired, or if you already work for the Company, may order additional background checks on you for employment purposes.  The Company may order an "investigative consumer report."  An "investigative consumer report" is a background check that includes information from personal interviews (except in California, where that term includes background checks with and without personal interviews).  The most common form of investigative consumer report is an investigation into your employment history.
  
The background check company, Private Eyes, Inc., will prepare the background report for the Company.  Private Eyes, Inc. is located at 190 North Wiget Lane, Suite 220, Walnut Creek, CA 94598, and can be reached toll free at 877-292-3331. The privacy policies for Private Eyes Inc. may be found at its website at www.privateeyesinc.com.

The background check may contain information concerning your character, general reputation, personal characteristics, mode of living, criminal history, credit worthiness, credit capacity and credit standing.  The types of information that may be ordered include, but are not limited to: criminal, public, educational, military and motor vehicle records checks; verification with the Department of Transportation; verification of prior employment and income; reference, licensing, and certification checks; credit reports; and Social Security number verification.  Information may be obtained from private and public record sources (including individuals, corporations, partnerships, law enforcement agencies, institutions, schools, credit bureaus, state licensing agencies and past and present employers), and for investigative consumer reports, from personal interviews with your associates, friends and neighbors.  Such inquiries may request information regarding instances of harassment, violence, theft or fraud.  You have the right to request more information about the nature and scope of an investigative consumer report, if any, by contacting the Company at 190 W Wiget Lane, Suite 220, Walnut Creek, CA 94598. 

STATE SPECIFIC NOTICES

If you live or work for the Company in any of the states listed below, please note the following:

CONNECTICUT: The Company will only obtain and use information about your credit history information for employment purposes if the information is substantially job-related within the meaning of applicable state law.  These purposes include to assess whether a candidate is qualified for certain positions.  You may request more information by contacting the Company.

CALIFORNIA:  You have a right to view the file that Private Eyes, Inc. has with your information, and order a copy of the file, upon submitting proper identification and paying copying costs, by coming to their offices, during normal business hours and on reasonable notice, or by mail.  You also may ask for a file-summary by telephone.  Private Eyes, Inc. can answer questions about information in your file including any coded information.  If you come to their offices in person, another person can join you, so long as that person can show proper identification.  The Company will only obtain and use information about your credit history information only as allowed by applicable state law.  You may request more information by contacting the Company.

MAINE:  If you contact the Company, you have the right to know within 5 business days whether the Company ordered an investigative consumer report about you, and if so, also to the address and telephone number of the nearest office for Private Eyes, Inc.  You have the right to ask Private Eyes, Inc. for a copy of any such report and to promptly receive the copy from Private Eyes, Inc.

MARYLAND:  The Company will only obtain and use information about your credit history information for employment purposes if the information is substantially job-related within the meaning of applicable state law.  These purposes include to assess whether a candidate is qualified for certain positions.  You may request more information by contacting the Company.

MASSACHUSETTS:  If you contact the Company, you have the right to know whether the Company ordered an investigative consumer report about you.  You also have the right to ask Private Eyes, Inc. for a copy of any such report. 

MINNESOTA:  You have the right in most circumstances to submit a written request to Private Eyes, Inc. for a complete and accurate disclosure of the nature and scope of any consumer report the Company ordered about you.  Private Eyes, Inc. must provide you with this disclosure within 5 days after its receipt of your request or the report was requested by the Company, whichever date is later.

NEW JERSEY:  You have the right to submit a request to Private Eyes, Inc. for a copy of any investigative consumer report the Company ordered about you. 

NEW YORK:  If you contact the Company, you have the right to know whether the Company ordered a consumer report or investigative consumer report about you.  Shown above is the address and telephone number for Private Eyes, Inc.  You have the right to contact Private Eyes, Inc. to inspect or receive a copy of any such report.  A copy of Article 23-A of the Correction Law is provided below.

OREGON:  The Company will only obtain and use information about your credit history information for employment purposes if the information is substantially job-related within the meaning of applicable state law.  These purposes include to assess whether a candidate is qualified for certain positions.  You may request more information by contacting the Company.

WASHINGTON STATE:  If you submit a written request to the Company, you have the right to a complete and accurate disclosure of the nature and scope of any investigative consumer report the Company ordered about you.  You are entitled to this disclosure within 5 days after the date your request is received or we ordered the report, whichever is later.  You also have the right to request a written summary of your rights under the Washington Fair Credit Reporting Act.  The Company will only obtain and use information about your credit history information for employment purposes if the information is substantially job-related within the meaning of applicable state law.  These purposes include to assess whether a candidate is qualified for certain positions.  You may request more information by contacting the Company.



BACKGROUND CHECK AUTHORIZATION

After carefully reading this Background Check Disclosure and Authorization form, I authorize the Company to order my background check, including investigative consumer reports.  I understand that the Company may rely on this authorization to order additional background checks, including investigative consumer reports, during my employment without asking me for my authorization again, as allowed by law.

I also authorize all of the following to disclose to Private Eyes, Inc. and its agents all information about or concerning me, including but not limited to: my past or present employers; learning institutions, including colleges and universities; law enforcement and all other federal, state and local agencies; federal state and local courts; the military; credit bureaus; testing facilities; motor vehicle records agencies; all other private and public sector repositories of information; the Department of Transportation, the military and any other person, organization, or agency with any information about or concerning me.  The information that can be disclosed to Private Eyes, Inc. and its agents includes, but is not limited to, information concerning my employment and earnings history, education, credit history, motor vehicle history, criminal history, military service, professional credentials and licenses, and may include inquiries regarding workers' compensation, harassment, violence, theft or fraud.

I agree that, as allowed by law, the Company may rely on this authorization to order background checks from companies other than Private Eyes, Inc. without asking me for my authorization again.  I also agree that a copy of this form is valid like the signed original.

I promise that all of my personal information on this form is true and correct and understand that dishonesty will disqualify me from consideration for employment with the Company, or if I am hired or already work for the Company, that my employment may be terminated.


Last Name ___
 First ___
Middle ___
Maiden Names ___
Years Used ___
Other Names ___
Years Used ___
Social Security Number ___
Driver's License Number ___
State ___
Other Driver's Licenses Held in Past 5 Years (include states) ___
FOR IDENTIFICATION PURPOSES ONLY:
Date of Birth          ___(Month/Day/Year)
Present Street Address ___
City/State/Zip ___
Residential Addresses Within Seven Years
Prior Street Address ___
City/State/Zip ___
From      ___ (Month/Day/Year)
To        ___(Month/Day/Year)

Prior Street Address ___
City/State/Zip ___
From      ___(Month/Day/Year)
To        ___(Month/Day/Year)

Prior Street Address ___
City/State/Zip ___
From      ___(Month/Day/Year)
To        ___(Month/Day/Year)

Signature (Full Name): ___  
I understand that by checking the following box and typing my name into the name field above, this document is as valid as if I have signed it. ___I agree.

Date: ___

If you live or work for the Company in California, Minnesota or Oklahoma: Check this box if you would like a free copy of your background check report: ___
Client Account Number: ___

Para informacion en espanol, visite www.consumerfinance.gov/learnmore o escribe a la Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20006.

NOTICE TO USERS OF CONSUMER REPORTS: Please click here to learn about the obligations of users under the FCRA.

A Summary of Your Rights Under the Fail Credit Reporting Act
     The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of information in the files of consumer reporting agencies. There are many types of consumer reporting agencies, including credit bureaus and specialty agencies (such as agencies that sell information about check writing histories, medical records, and rental history records). Here is a summary of your major rights under the FCRA. For more information, including information about additional rights, go to www.consumerfinance.gov/learnmore or write to: Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20006.
  • You must be told if information in your file has been used against you. Anyone who uses a credit report or another type of consumer report to deny your application for credit, insurance, or employment - or to take another adverse action against you - must tell you, and must give you the name, address, and phone number of the agency that provided the information.
  • You have the right to know what is in your file. You may request and obtain all the information about you in the files of a consumer reporting agency (your "file disclosure"). You will be required to provide proper identification, which may include your Social Security number. In many cases, the disclosure will be free. You are entitled to a free file disclosure if:
    • a person has taken adverse action against you because of information in your credit report;
    • you are the victim of identify theft and place a fraud alert in your file;
    • your file contains inaccurate information as a result of fraud;
    • you are on public assistance;
    • you are unemployed but expect to apply for employment within 60 days.

    In addition, by September 2005 all consumers will be entitled to one free disclosure every 12 months upon request from each nationwide credit bureau and from nationwide specialty consumer reporting agencies. See www.consumerfinance.gov/learnmore for additional information.
  • You have the right to ask for a credit score. Credit scores are numerical summaries of your credit-worthiness based on information from credit bureaus. You may request a credit score from consumer reporting agencies that create scores or distribute scores used in residential real property loans, but you will have to pay for it. In some mortgage transactions, you will receive credit score information for free from the mortgage lender.
  • You have the right to dispute incomplete or inaccurate information. If you identify information in your file that is incomplete or inaccurate, and report it to the consumer reporting agency, the agency must investigate unless your dispute is frivolous. See www.consumerfinance.gov/learnmore for an explanation of dispute procedures.
  • Consumer reporting agencies must correct or delete inaccurate, incomplete, or unverifiable information. Inaccurate, incomplete or unverifiable information must be removed or corrected, usually within 30 days. However, a consumer reporting agency may continue to report information it has verified as accurate.
  • Consumer reporting agencies may not report outdated negative information. In most cases, a consumer reporting agency may not report negative information that is more than seven years old, or bankruptcies that are more than 10 years old.
  • Access to your file is limited. A consumer reporting agency may provide information about you only to people with a valid need -- usually to consider an application with a creditor, insurer, employer, landlord, or other business. The FCRA specifies those with a valid need for access.
  • You must give your consent for reports to be provided to employers. A consumer reporting agency may not give out information about you to your employer, or a potential employer, without your written consent given to the employer. Written consent generally is not required in the trucking industry. For more information, go to www.consumerfinance.gov/learnmore.
  • You may limit "prescreened" offers of credit and insurance you get based on information in your credit report. Unsolicited "prescreened" offers for credit and insurance must include a toll-free phone number you can call if you choose to remove your name and address from the lists these offers are based on. You may opt-out with the nationwide credit bureaus at 888-5-OPT-OUT (888-567-8688) or www.optoutprescreen.com.
  • You may seek damages from violators. If a consumer reporting agency, or, in some cases, a user of consumer reports or a furnisher of information to a consumer reporting agency violates the FCRA, you may be able to sue in state or federal court.
  • Identity theft victims and active duty military personnel have additional rights. For more information, visit www.consumerfinance.gov/learnmore.
States may enforce the FCRA, and many states have their own consumer reporting laws. In some cases, you may have more rights under state law. For more information, contact your state or local consumer protection agency or your state Attorney General Federal enforcers are:

TYPE OF BUSINESS: CONTACT:
1.a. Banks, savings associations, and credit unions with total assets over $10 billion and their affiliates

b. Such affiliates that are not banks, saving associates, or credit unions also should list, in addition to the Bureau:
a. Bureau of Consumer Financial Protection
1700 G Street NW
Washington, DC 20006

b. Federal Trade Commission: Consumer Response Center - FCRA
Washington, DC 20580
(877) 382-4357
2. To the extent not included in item 1 above:

a. National banks, federal savings associations, and federal agencies of foreign banks

b. State member banks, branches and agencies of foreign banks (other than federal branches, federal agencies, and insured state branches of foreign banks), commercial lending companies owned or controlled by foreign banks, and organizations operating under section 25 or 25A of the Federal Reserve Act.

c. Nonmember Insured Banks, Insured State Branches of Foreign Banks, and insured state savings associations

d. Federal Credit Unions
a. Office of the Comptroller of the Currency
Customer Assistance Group
1301 McKinney Street, Suite 3450
Houston , TX 77010-9050

b. Federal Reserve Consumer Help Center
P.O. Box 1200
Minneapolis, MN 55480

c. FDIC Consumer Response Center
1100 Walnut Street, Box #11
Kansas City, MO 64106

d. National Credit Union Administration
Office of Consumer Protection (OCP)
Division of Consumer Compliance and Outreach (DCCO)
1775 Duke Street
Alexandria, VA 22314
3. Air carriers Asst. General Counsel for Aviation Enforcement & Proceedings
Department of Transportation
400 Seventh Street SW
Washington, DC 20590
4. Creditors Subject to Surface Transportation Board Office of Proceedings, Surface Transportation Board
Department of Transportation
1925 K Street NW
Washington, DC 20423
5. Creditors Subject to Packers and Stockyards Act Nearest Packers and Stockyards Administration area supervisor
6. Small Business Investment Companies Associate Deputy Administrator for Capital Access
United States Small Business Administration
409 Third Street, SW 8th Floor
Washington, DC 20416
7. Brokers and Dealers Securities and Exchange Commission
100 F St NE
Washington, DC 20549
8. Federal Land Banks, Federal Lank Bank Associations, Federal Intermediate Credit Banks, and Production Credit Associations Farm Credit Administration
1501 Farm Credit Drive
McLean, VA 22102-5090
9. Retailers, Finance Companies, and All Other Creditors Not Listed Above FTC Regional Office for region in which the creditor operates ­or Federal Trade Commission: Consumer Response Center – FCRA Washington, DC 20850
(877) 382-4357 


(NEW YORK APPLICANTS ONLY)
ARTICLE 23-A, NEW YORK STATE CORRECTION LAW
§  750.  Definitions.  For the purposes of this article, the following  terms shall have the following meanings:
(1)  "Public agency" means the state or any local subdivision  thereof, or any state or local department, agency, board or commission.
(2)  "Private employer" means any person, company, corporation, labor organization or association which employs ten or more persons.
(3)  "Direct relationship" means that the nature of criminal  conduct for which  the person was convicted has a direct bearing on his fitness or ability to perform one or more of the duties or responsibilities necessarily related to the license, opportunity, or job in question.
(4)  "License" means any certificate, license, permit or grant of permission required by the laws of this state, its political subdivisions or instrumentalities as a condition for the lawful practice of any occupation, employment, trade, vocation, business, or profession.  Provided, however, that "license" shall not, for the purposes of this article, include any license or permit to own, possess, carry, or fire any explosive, pistol, handgun, rifle, shotgun, or other firearm.
(5)  "Employment" means any occupation, vocation or employment, or any form of vocational or educational training.  Provided, however, that "employment" shall not, for the purposes of this article, include membership in any law enforcement agency.

§  751.  Applicability.  The provisions of this article shall apply to any application by any person for a license or employment at any public or private employer, who has previously been convicted of one or more criminal offenses in this state or in any other jurisdiction, and to any license or employment held by any person whose conviction of one or more criminal offenses in this state or in any other jurisdiction preceded such employment or granting of a license, except where a mandatory forfeiture, disability or bar to employment is imposed by law, and has not been removed by an executive pardon, certificate of relief from disabilities or certificate of good conduct.  Nothing in this article shall be construed to affect any right an employer may have with respect to an intentional misrepresentation in connection with an application for employment made by a prospective employee or previously made by a current employee.

§  752.  Unfair discrimination against persons previously convicted of one or more criminal offenses prohibited.  No application for any license or employment, and no employment or license held by an individual, to which  the provisions of this article are applicable, shall be denied or acted upon adversely by reason of the individual's having been previously convicted of one or more criminal offenses, or by reason of a finding of lack of "good moral character" when such finding is based upon the fact that the individual has previously been convicted of one or more criminal offenses, unless:
(1) there is a direct relationship between one or more of the previous criminal offenses and the specific license or employment sought or held by the individual; or
(2) the issuance or continuation of the license or the granting or continuation of the employment would involve an unreasonable risk to property or to the safety or welfare of specific individuals or the general public.

§  753.  Factors to be considered concerning a previous criminal conviction; presumption. 
1.  In making a determination pursuant to section seven hundred fifty-two of this chapter, the public agency or private employer shall consider the following factors:
(a) The public policy of this state, as expressed in this act, to encourage the licensure and employment of persons previously convicted of one or more criminal offenses.
(b) The specific duties and responsibilities necessarily related to the license or employment sought or held by the person.
(c)  The bearing, if any, the criminal offense or offenses for which the person was previously convicted will have on his fitness or ability to perform one or more such duties or responsibilities.
(d)  The time which has elapsed since the occurrence of the criminal offense or offenses.
(e) The age of the person at the time of occurrence of the criminal offense or offenses.
(f) The seriousness of the offense or offenses.
(g) Any information produced by the person, or produced on his behalf, in regard to his rehabilitation and good conduct.
(h)  The legitimate interest of the public agency or private employer in protecting property, and the safety and welfare  of specific individuals or the general public.
2.  In making a determination pursuant to section seven hundred fifty-two of this chapter, the public agency or private employer shall also give consideration to a certificate of relief from disabilities or a certificate of good conduct issued to the applicant, which certificate shall create a presumption of rehabilitation in regard to the offense or offenses specified therein.

§  754.  Written statement upon denial of license or employment.  At the request of any person previously convicted of one or more criminal offenses who has been denied a license or employment, a public agency or private employer shall provide, within thirty days of a request, a written statement setting forth the reasons for such denial.

§  755.  Enforcement.
1.  In relation to actions by public agencies, the provisions of this article shall be enforceable by a proceeding brought pursuant to article seventy-eight of the civil practice law and rules.
2.  In relation to actions by private employers, the provisions of this article shall be enforceable by the division of human rights pursuant to the powers and procedures set forth in article fifteen of the executive law, and, concurrently, by the New York city commission on human rights.



Application Addendum
Name: 


                            Application Addendum



1  Have you ever been convicted of a crime, had adjudication of a crime withheld, or pled nolo
    contendere to a crime?
    
    If yes, please state the circumstances with regard to each.
   

2.  Have you been arrested for any crime that had not been adjudicated?
     
     If yes, please state the circumstances and current status of each arrest.
    
    
    

3.  Have you ever committed a crime for which you were not arrested or convicted?
    
    If yes, please state the circumstances.
    
    

4.  Have you ever been a defendant in a civil action for intentional tort?  Intentional tort commonly refers to
      examples, such as assault, battery, and false imprisonment:
   
    If yes, please state the circumstances.
     
     

     

* Note:  Answering "Yes" to any of these questions may not necessarily disqualify you from the position desired.
Each action and explanation will be weighted / considered in relationship to the position for which you are applying. HRDATA\FORMS\APPLKT\ADDENDUM

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