METRO INTERFAITH HOUSING MANAGEMENT CORP.

Application for Employment

Metro Interfaith Housing Management Corp.

21 New Street

Binghamton, New York 13903-1759

_____________________________________ Full-Time Regular Part-Time Regular Hourly

Title of Position Applying For (Circle One)

No persons shall be denied equal protection of the laws of this County, State, Nation or any subdivision thereof. No person shall, because of race, color, creed, religion, age, sex national origin or sponsor, be subject to any discrimination in his/her civil rights by any person, department or any agency or subdivision of Metro Interfaith. The New York State Human Rights Law prohibits discrimination because of age. Metro Interfaith does not discriminate on the basis of physical or mental disability and will make reasonable accommodations for individuals with disabilities during the application, examination, interviewing and employment.

METRO INTERFAITH IS AN EQUAL OPPORTUNITY EMPLOYER

A clear understanding of your background and work history will aid us in placing you in a position that best meets your qualifications.

DIRECTIONS: Please print using black ink or type. Answer all questions, write “No” or “None” where applicable.

NAME ______________________________________________ SOC. SEC. NUMBER _________________

Last First Middle

LEGAL ADDRESS ________________________________________________________________________

Street County

__________________________________________________________________________________________

City State Zip Code

MAILING ADDRESS ______________________________________________________________________

(If Different From Above) Street City State/Zip Code

PHONE NUMBER HOME (_____) ________________________ WORK (____) _____________________

(Please notify immediately of any changes.)

EDUCATION Circle last grade completed- 6 7 8 9 10 11 12 13 14 15 16 17 18

Name and School Address Graduated? Type of Degrees No. of credits

Yes or No completed

High School

Last attended

Colleges or

Universities

Other

EMPLOYMENT EXPERIENCE

List all permanent employment since High School. List any employment that may tend to qualify you for the position sought. If additional space is required, use supplemental sheets. Start with your most recent or current position.

Company Name: Phone Number:

Type of Business:

Address:

Your Position Title:

Supervisor’s Name:

and Title:

Employed From (date) To (date)

Salary: Starting Final Hours/Week

Describe your duties and responsibilities in detail

Reason for leaving (please explain fully) _________________________________________________________________

Company Name: Phone Number:

Type of Business:

Address:

Your Position Title:

Supervisor’s Name:

and Title:

Employed From (date) To (date)

Salary: Starting Final Hours/Week

Describe your duties and responsibilities in detail

Reason for leaving (please explain fully) _________________________________________________________________

__________________________________________________________________________________________________

Company Name: Phone Number:

Type of Business:

Address:

Your Position Title:

Supervisor’s Name:

and Title:

Employed From (date) To (date)

Salary: Starting Final Hours/Week

Describe your duties and responsibilities in detail

Reason for leaving (please explain fully) _________________________________________________________________

Company Name: Phone Number:

Type of Business:

Address:

Your Position Title:

Supervisor’s Name:

and Title:

Employed From (date) To (date)

Salary: Starting Final Hours/Week

Describe your duties and responsibilities in detail

Reason for leaving (please explain fully) _________________________________________________________________

__________________________________________________________________________________________________

PERSONAL DATA

Do you have the legal right to accept employment in the United States? ____ Yes ___ No

Have you ever been convicted of a misdemeanor or felony? ____ Yes ___No

If a motor vehicle license is required for the position for which you are applying, please indicate the license you presently hold:

Class A B C D E (circle one) Designate type of commercial license _______________

Date of Expiration ____________/ ____________/ ____________

month day year

If a license, certificate or other authorization to practice a trade or profession is a requirement for the position for which you are applying, please indicate the following:

Name of Trade or Profession: _________________________________________________________________________

License Number: ______________________________________ Date From ________________ To ________________

Licensing Agency: _____________________________________ City/State ____________________________________

For reference purposes do you have any objections to our contacting present or past employers? ____ Yes ____ No

Have you served in the United States Armed Forces? ____ Yes ____ No

Branch _______________________

Did you receive a dishonorable discharge? ____ Yes ____ No

Note: A dishonorable discharge is not an absolute bar to employment, other factors will affect a final decision.

What made you aware of this vacancy or employment opportunities with Metro Interfaith Housing Management Corp.

Friend/Relative _____ Radio ____ Newspaper ____ Other ____

DECLARATION

I agree, if employed, to abide by all the rules and regulations relative to my position. If required. I agree to undergo a physical examination and authorize the examining physician to release the results to the Personnel Department I declare that the statements made in this application ( including statements made in any accompanying papers) have been examined by me and to the best of my knowledge and belief are true and correct. I understand that any omission, misrepresentation and/or falsification of information contained in this application may constitute grounds for my dismissal. I give Metro Interfaith the right to investigate all references and to secure additional job related information about me. I hereby release from liability Metro Interfaith and its representatives for seeking information and all other persons, corporations or organizations for furnishing such information.

Signature ________________________________ Date _________________________

Please print any other surnames (last names) by which you are or have been known.

_____________________________________________

The Immigration Reform and Control Act of 1986, requires that all individuals must provide acceptable documentation that provides identity and employment eligibility. A listing of acceptable documents can be obtained from the Personnel Department. Failure to provide this documentation will affect your chances for employment with Metro Interfaith.

APPLICATIONS WILL BE HELD ON FILE FOR ONE YEAR FROM FILING DATE.

VOLUNTARY

EQUAL OPPORTUNITY DATA RECORD

Metro Interfaith Housing Management Corp. is an equal opportunity employer. Qualified applicants and employees are treated without regard to race, color, religion, sex, national origin, age, marital status, veteran status, or unrelated medical conditions or disability.

As an equal opportunity employer Metro Interfaith Housing Management Corp. complies with all relevant government regulations and affirmative action responsibilities. Solely to help us with equal opportunity record keeping, reporting and other legal requirements, please fill out this Data Record. Submission of this information is voluntary.

This information will not be used as selection criteria and will be treated as confidential. This information will be kept separate from your employment application.

Date: _____/_____/_____

Check One: Check Only One: (If you belong to more than one

Group, select the one that is most appropriate.)

____ Male ____ White (not of Hispanic origin)

____Female ____ Black (not of Hispanic origin)

____ Asian/Pacific Islander

____ American Indian/ Alaska Native

____ Hispanic

Check if any of the following are applicable:

____ Vietnam era Veteran

____ Disabled individual

____ Disabled Veteran

For the position you are applying for, are there any reasonable accommodations we could make which would enable you to perform the job properly and safely? ____ Yes ____ No.

If yes, please explain:

WHITE

(Not of Hispanic origin) – All persons having origins in any of the original peoples of Europe, North Africa, or the Middle East.

BLACK

(Not of Hispanic origin) – All persons having origins in any of the Black racial groups of Africa.

AMERICAN INDIAN OR ALASKAN NATIVE

All persons having origins in and of the original peoples of North America, and who maintain cultural identification through tribal affiliation or community recognition.

HISPANIC

All persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of race.

DISABLED VETERAN

The term “special disabled veteran” means (1) a veteran who is entitled to compensation under laws administered by the Veterans’ Administration for a disability rated at 30 percent or more, or (2) a person who was discharged or released from active duty because of a service connected disability.

VETERAN OF THE VIETNAM ERA

The term “veteran of the Vietnam era” means an “eligible veteran” any part of whose active military, naval or air service was during the “Vietnam Era”. The term “eligible veteran” means a person who (1) served on active duty for a period of more than 180 days and was discharged, or (2) was discharged or released from active duty because of a service connected disability. The term “Vietnam Era”, according to regulations promulgated by OFCCP, appears to encompass the period between August 5, 1964 and May 7, 1975.

DISABLED INDIVIDUALS

The term ‘disabled individual” means any person who (1) has a physical or mental impairment which “substantially limits” one or more of such person’s major life activities, (2) has a record of such impairment, or (3) is regarded as having such an impairment. A disability is “substantially limiting” if it is likely to cause difficulty in securing, retaining or advancing in employment.

PERSONAL REFERENCES

NAME: _______________________________________________________________________

ADDRESS: _______________________________________________________________________

TELEPHONE: DAY ( )_______________________ EVENING ( ) ___________________________