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Applicant's Statement

I hereby certify that this application contains no misrepresentations or falsifications and that the information given is true and complete to the best of my knowledge. I understand that misrepresentation or omission of facts called for in this application is cause for cancellation of the application and/or dismissal from employment. I authorize InfoTechNy to make any necessary and appropriate investigations to verify the information contained herein, and release from all liability any persons, companies, or corporations supplying information pertaining to me.

Signature of applicant ______________________________________________ Date __________

For Personnel Department Use Only

Arrange Interview Yes No

Remarks_______________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

Interviewer______________________________________ Date_________________

Job Title_______________________ Dept. ______________________ Hourly Rate/Salary___________

By_____________________________________________

Name and Title

Notes

Please print this form, fill it out and then fax it or mail it to us, Thank you. Date_________________		1512 East 36th street Brooklyn, NY 11234 TEL.718-758-1600 FAX.718-758-1700	Application For Employment
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Position Applied For			Date of Application

Last Name		First Name	Middle Name
Mailing Address	City	State	Zip Code
Telephone Number(s)		Social Security Number
Driver's License	State	Number


If you are under 18 years of age, can you provide required proof of your eligibility to work?			Yes No
Have you ever been employed with us before?			Yes No
If Yes, give date		____________________________
Are you currently employed?			Yes No
May we contact your present employer?			Yes No
Are you available to work: Full Time Part Time Temporary

On what date would you be available for work? _________________________________________

Do you have any certifications?_______________________________________________________________________________

Education
	Elementary School	High School	Undergraduate College/University	Graduate/ Professional
School Name/Location
Years Completed
Diploma/Degree
Describe Course of Study
Describe any specialized training, apprenticeship, skills and extra-curricular actrivities
Describe any honors you have received
State any additional information you feel may be helpful to us in considering your application

Have you ever had any job-related training in the United States military?				Yes No
If Yes, please describe:



References
Give the name, address and telephone number of three references who are not related to you and are not previous employers.
1.
2.
3.

Work Experience
Starting with your present or last job, describe your work experience during the past 10 years. Include any job-related military service assignments and volunteer activities.
Employer		Dates Employed		Work Performed
Address		From	To
Telephone Number		Hourly Rate/Salary
Job Title	Supervisor	Starting	Final
Reason for Leaving
Employer		Dates Employed		Work Performed
Address		From	To
Telephone Number		Hourly Rate/Salary
Job Title	Supervisor	Starting	Final
Reason for Leaving
Employer		Dates Employed		Work Performed
Address		From	To
Telephone Number		Hourly Rate/Salary
Job Title	Supervisor	Starting	Final
Reason for Leaving
Employer		Dates Employed		Work Performed
Address		From	To
Telephone Number		Hourly Rate/Salary
Job Title	Supervisor	Starting	Final
Reason for Leaving
Employer		Dates Employed		Work Performed
Address		From	To
Telephone Number		Hourly Rate/Salary
Job Title	Supervisor	Starting	Final
Reason for Leaving
If you require additional space, please continue on a separate sheet of paper.

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