NYS Employment Application: Part 1 Pre-Interview Form #S1000 Instructions

Check this box if additional sheets are attached to this form. Fill only if 'Has your license/certification/registration ever been suspended or revoked?' is 'Yes'.

Check this box if no additional sheets are attached to this form.

Please provide any additional comments or remarks you wish to include. Fill only if 'Has your license/certification/registration ever been suspended or revoked?' is 'Yes'.

Check this box if you have attached additional sheets to provide more information for this section.

Check this box if you have not attached any additional sheets for this section.

Please enter the date when the affirmation and release authorization was signed.

Please enter the full name of the applicant as it appears in their signature.

Please provide the applicant's last name.

Please provide the applicant's middle initial.

Please provide the applicant's first name.

Please enter the applicant's full legal name.

Please enter the full name of the applicant.

Please provide your full legal name.

Please list any endorsements or restrictions applicable to your Commercial Driver License (CDL). Fill only if 'Class A', 'Class B', 'Class C' is 'Yes', when any are selected.

Check this box if you will intern, volunteer, or maintain employment concurrently elsewhere if offered a position with this agency.

Check this box if you will not intern, volunteer, or maintain employment concurrently elsewhere if offered a position with this agency.

Enter the county where you currently reside.

Please enter the first line of your current mailing or street address.

Please enter the city for your current mailing or street address.

Please enter the zip code for your current mailing or street address.

Please enter the state for your current mailing or street address.

Check this box if your driver's license is a Class A license. Fill only if 'Yes' is 'Yes'.

Check this box if your driver's license is a Class B license. Fill only if 'Yes' is 'Yes'.

Check this box if your driver's license is a Class C license. Fill only if 'Yes' is 'Yes'.

Check this box if your driver's license is a Class D license. Fill only if 'Yes' is 'Yes'.

Check this box if your driver's license is a Class E license. Fill only if 'Yes' is 'Yes'.

Please specify the other driver's license class if applicable. Fill only if 'Class E' is 'Yes'.

Provide the state where your driver's license was issued. Fill only if 'Yes' is 'Yes'.

Enter your driver's license number. Fill only if 'Yes' is 'Yes'.

Enter the expiration date of your driver's license. Fill only if 'Yes' is 'Yes'.

Check this box if you currently have a valid driver license that allows you to operate a motor vehicle in New York State.

Check this box if you do not currently have a valid driver license that allows you to operate a motor vehicle in New York State.

Please enter your current email address.

Check this box if you will now, or in the future, require sponsorship for employment visa status.

Check this box if you will not now, or in the future, require sponsorship for employment visa status.

Please provide the name of the institution or authority that issued the equivalency program.

Please provide the identification number of the equivalency program.

Please provide the number of credits obtained at the first college or university.

Please provide the major and/or minor courses of study pursued at the first college or university.

Please provide the name and location of the first college or university attended.

Please provide the name of the diploma or degree received from the first college or university.

Enter the name of your present or last employer.

Enter the full street address of your present or last employer.

Enter the full name of your direct supervisor at this employer.

Enter the job title of your direct supervisor at this employer.

Enter your job title and describe your duties and responsibilities at this employer.

Enter the telephone number, including the area code, for this employer.

Explain the reason(s) for leaving your employment with this employer.

If this is your current employer, specify the date or timeframe when they may be contacted.

Enter the starting month of employment.

Enter the starting day of employment.

Enter the starting year of employment.

Enter the ending month of employment.

Enter the ending day of employment.

Enter the ending year of employment.

Please provide the name and location of the military school or other training program.

Please enter the total number of credits earned from this military school or training program.

Please specify the unit type for the credits earned, such as semester hours or quarter units.

Please list the main courses of study or major/minor areas from this military school or training program.

Please enter the diploma or degree received from this military school or training program.

Please provide the full name of the professional reference.

Please provide the first line of the professional reference's address.

Please describe your professional relationship with this reference.

Please provide the telephone number of the professional reference.

Please provide the email address of the professional reference.

Please provide the second line of the professional reference's address. Fill only if 'Reference Address Line 1' has a value.

Enter the total number of credits received from the vocational or technical school.

Enter the name and location of the vocational or technical school.

Enter the major or minor courses of study pursued at the vocational or technical school.

Enter the diploma or degree received from the vocational or technical school.

Enter the name and location of the fourth college or university you attended.

Enter the courses of study, major, or minor pursued at the fourth college or university.

Enter the total number of credits received from the fourth college or university.

Enter the diploma or degree received from the fourth college or university.

Check this box if you are able to perform permanent work.

Check this box if you are unable to perform permanent work.

Check this box if you are able to perform temporary work.

Check this box if you are unable to perform temporary work.

Check this box if you are able to perform seasonal work.

Check this box if you are unable to perform seasonal work.

Check this box if you are able to perform work only during the summer.

Check this box if you are unable to perform work only during the summer.

Check this box if you are able to perform work only during the winter.

Check this box if you are unable to perform work only during the winter.

Provide the full name and location of the high school you attended.

Enter the total number of academic credits earned at the high school.

Specify the diploma or degree awarded upon completion of your high school education.

List the major and minor courses of study completed at the high school.

Check this box if you are able to work shift work.

Check this box if you are not able to work shift work.

Check this box if you are able to work overtime.

Check this box if you are not able to work overtime.

Please enter the type of work or position you are interested in.

Please enter the geographic work location(s) you are interested in.

Check this box if you are legally authorized to work in the United States.

Check this box if you are not legally authorized to work in the United States.

Check this box if your professional license, certification, or registration has ever been suspended or revoked.

Check this box if your professional license, certification, or registration has never been suspended or revoked.

Check this box if this question regarding license suspension or revocation is not applicable to you.

Please enter your full name as it should appear on the application.

Provide your New York State Employee ID if one has been assigned to you.

Provide any other names, including nicknames, by which you have been known.

Please provide your permanent street address, if it is different from the current mailing address. Fill only if 'Street Address Line 1' is different from the Current Mailing/Street Address.

Please enter your home phone number, including the area code.

Please enter your business phone number, including the area code.

Please enter your cell phone number, including the area code.

Please enter your printed name.

Check this box if you have any conditional limitations or restrictions on your ability to practice under your professional license, certification, or registration.

Check this box if you do not have any conditional limitations or restrictions on your ability to practice under your professional license, certification, or registration.

Check this box if the question about conditional limitations or restrictions on your professional license, certification, or registration is not applicable to you.

Please provide the name of the trade or professional license/certificate.

Please specify the type or specialty of the professional license or certificate.

Please provide the name of the authority or organization that issued the license or certificate.

Please enter the license or certificate number.

Please provide the date when the license or certificate was issued.

Please provide the date when the license or certificate will expire.

Please provide the date when the license or certificate was registered.

Please provide the date when the registration for the license or certificate will expire.

Please provide the full name of the relative employed by the agency. Fill only if 'No Relatives Employed' is 'No'.

Please describe your relationship to the relative mentioned. Fill only if 'No Relatives Employed' is 'No'.

Check this box if you do not have any relatives employed by the agency with which you are seeking employment.

Check this box if you are able to work Saturday hours.

Check this box if you are unable to work Saturday hours.

Check this box if you are able to work Sunday hours.

Check this box if you are unable to work Sunday hours.

Check this box if you are able to work full-time.

Check this box if you are unable to work full-time.

Check this box if you are able to work part-time.

Check this box if you are unable to work part-time.

Check this box if you are able to work on a per diem basis.

Check this box if you are unable to work on a per diem basis.

Enter the major or minor courses of study pursued at the second college or university.

Enter the name and location of the second college or university attended.

Enter the total number of credits earned at the second college or university.

Enter the diploma or degree received from the second college or university.

Please provide the full name of your present or last employer.

Please provide the full street address of your present or last employer.

Please provide the full name of your immediate supervisor at this employer.

Please provide the job title of your immediate supervisor at this employer.

Please describe your job title and duties at this employer, the reason(s) for leaving (if applicable), and indicate when we may contact your current employer (if this is your current employer).

Please provide the area code and telephone number for this employer.

Please provide the month for the start date of your employment with this employer.

Please provide the day for the start date of your employment with this employer.

Please provide the year for the start date of your employment with this employer.

Please provide the month for the end date of your employment with this employer.

Please provide the day for the end date of your employment with this employer.

Please provide the year for the end date of your employment with this employer.

Please provide the name of the second other training or military school.

Please provide the courses of study (major/minor) at the second other training or military school.

Please provide the number of credits obtained from the second other training or military school.

Please provide the diploma or degree received from the second other training or military school.

Enter the full name of the second professional reference.

Enter the first line of the second professional reference's address.

Enter your relationship to the second professional reference.

Enter the telephone number of the second professional reference.

Enter the email address of the second professional reference.

Enter the second line of the second professional reference's address. Fill only if 'Second Reference Address Line 1' has a value.

List the courses of study (major and/or minor) pursued at the second vocational or technical school.

Provide the name and location of the second vocational or technical school attended.

Enter the number of credits received from the second vocational or technical school.

State the diploma or degree received from the second vocational or technical school.

Enter the last four digits of your Social Security Number.

Provide details regarding the suspension or revocation of your license, certification, or registration. Fill only if 'Limitations Yes', 'Yes' is 'Yes', when any are selected.

Please provide the type of your teacher certification, such as Initial, Provisional, Permanent, or Professional.

Provide the name and location of the third college or university attended.

Enter the number of credits earned for the third college or university.

Provide the major and/or minor courses of study for the third college or university.

State the diploma or degree received from the third college or university.

Enter the name of your present or last employer.

Provide the full address of this employer.

Enter the name of your direct supervisor at this employer.

Provide the job title of your direct supervisor at this employer.

Describe your job title and responsibilities at this employer.

Enter the area code and telephone number for this employer.

Explain the reason(s) for leaving this employment.

Specify when it is acceptable for the agency to contact your current employer, if applicable.

Enter the starting month of your employment.

Enter the starting day of your employment.

Enter the starting year of your employment.

Enter the ending month of your employment.

Enter the ending day of your employment.

Enter the ending year of your employment.

Provide the date you would be available to start work if offered a position.

Check this box if you are under 18 and can provide a work permit.

Check this box if you are under 18 and cannot provide a work permit.

Check this box if you are 18 or older and the question about a work permit is not applicable to you.