GATEWAY-LONGVIEW ONLINE JOB APPLICATION

 Personal Information      * Required Fields

Gateway-Longview is an equal opportunity employer and affords equal opportunity to all applicants for all positions without regard to race, color, religion, gender, sexual orientation, national origin, age, disability, veteran status, domestic violence victim status, marital status or any other legally protected status or the presence of a medical or physical condition which, with reasonable accommodation, does not interfere with the applicant’s ability to perform the essential functions of the position sought.

* Position Desired:

* How were you referred:




Other:

* Full Name:

* Address:

* City:

* State:

* Zip:

* Your E-mail:


PLEASE NOTE: A copy of your completed employment
application will be sent to the email address you provide.

* Phone:

* Mobile/Other:

* Valid NYS Driver's License:

* 18 Years or Older:

* If NO, please explain:

* Shift Available: (select one or more):


* Ever worked
here before?:

* If YES, When:

* Ever before applied for a
position at Gateway-Longview?:

* If YES, When:

* Type of employment you are seeking:


* Are you legally eligible for employment in the United States?:

* Have you ever been convicted of a felony or misdemeanor in New York State or any other jurisdiction?

* If YES, give dates/details:

Note: Information regarding conviction record will not necessarily bar applicant from employment
but will be considered in light of duties related to position sought.

* Have you ever been excluded from participating in any federally funded health care program, including Medicaid and Medicare?

   
   Education:
High School: Graduated?:
City/State:
# of Years attended: Majored: Degree:
Trade/Business School: Graduated ?:
City/State:
# of Years attended: Majored: Degree:
College
(undergraduate):		 Graduated ?:
City/State:
# of Years attended: Majored: Degree:
College
(graduate):		 Graduated ?:
City/State:
# of Years attended: Majored: Degree:
   PROFESSIONAL LICENSES/CERTIFICATIONS:
Certificate/License:
State Issued:
Date Received Expiration Date:    
Certificate/License:
State Issued:
Date Received Expiration Date:    
Certificate/License:
State Issued:
Date Received Expiration Date:    
   Previous Employment (begin with most recent position):
Dates of Employment: From:   To:   
Positions(s) Held:
Employer Name:
Supervisor:  
Title of Supervisor:  
Starting Salary:  
Ending Salary:  
Reason for Leaving:  
   
   Previous Employment (begin with most recent position):
Dates of Employment: From:   To:   
Positions(s) Held:
Employer Name:
Supervisor:  
Title of Supervisor:  
Starting Salary:  
Ending Salary:  
Reason for Leaving:  
   
   Previous Employment (begin with most recent position):
Dates of Employment: From:   To:   
Positions(s) Held:
Employer Name: 
Address of Employer:  
Phone Number:  
Supervisor:  
Title of Supervisor:  
Starting Salary:  
Ending Salary :  
Reason for Leaving:  
   
   Previous Employment (begin with most recent position):
Dates of Employment: From:   To:   
Positions(s) Held:
Employer Name: 
Address of Employer:  
Phone Number:  
Supervisor:  
Title of Supervisor:  
Starting Salary:  
Ending Salary:  
Reason for Leaving:  
   Previous Employment (begin with most recent position):
Dates of Employment: From:   To:   
Positions(s) Held:
Employer Name: 
Address of Employer:  
Phone Number:  
Supervisor:  
Title of Supervisor:  
Starting Salary:  
Ending Salary :  
Reason for Leaving:  
   
   Reference (Please list at least three references below. Please provide at least two references who were former employers, including one who was a direct supervisor.)
Name:

Position/Employer
(if applicable):
Relationship
(i.e. supervisor,
co-worker, mentor):		  
Phone Number
(required) &
Email Address
(if available): 		 
   Reference
Name:

Position/Employer
(if applicable):
Relationship
(i.e. supervisor,
co-worker, mentor):		  
Phone Number
(required) &
Email Address
(if available): 		 
   Reference
Name:

Position/Employer
(if applicable):
Relationship
(i.e. supervisor,
co-worker, mentor):		  
Phone Number
(required) &
Email Address
(if available): 		 
   Reference
Name:

Position/Employer
(if applicable):
Relationship
(i.e. supervisor,
co-worker, mentor):		  
Phone Number
(required) &
Email Address
(if available): 		 


APPLICANT'S STATEMENT

AUTHORIZATION

You must agree to the below statement in order to be considered for employment with Gateway-Longview.
Please read carefully:
1. I hereby authorize Gateway-Longview to contact any of the references or employers I have provided above for purposes of obtaining any and all information concerning my previous employment and any pertinent information regarding my background, performance history and professional qualifications. I hereby release Gateway-Longview and its representatives and any former employer or reference from liability arising out of any information they seek or provide in connection herewith.

2. I understand that if I am given a conditional offer of employment, additional screening prior to hire will include the following: a physical exam, drug screen, criminal background check, DMV check, social security number verification, reference checks and clearance through the Sex Offender Registry Information Line of NYS and the NYS Central Register of Child Abuse and Maltreatment. I hereby consent to these screens and understand that such offer is conditioned upon satisfactory results of the screenings as listed above. In addition, I understand the refusal to submit to any of the screenings will result in my conditional offer of employment being rescinded.

3. I hereby certify that the information I have provided on this application and its attachments is true and correct to the best of my knowledge and that no attempt has been made by me to conceal any pertinent information. I understand that any material error or omission of information may constitute grounds for denial of employment or subject me to termination at any time during my employment.

4. I understand that nothing contained in this application or conveyed during any interview which may be granted is intended to create an employment contract.


I agree to the AUTHORIZATION

Please Note: When selecting "Send" a copy of your completed employment
application will be sent to you at the email address you provided.