Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Present Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number *

(###)

###

####

Date You Can Start *

MM

DD

YYYY

Hours *

Full Time

Part Time

Per-Diem

Do you hold any of the following NYS Peer Credentials? Check all that apply.

NYS Peer Specialist

NYS Certified Peer Recovery Advocate

NYS Family Peer Advocate

NYS Youth Peer Advocate

Are you willing to work overtime? *

Yes

No

If driving is a requirement of the job for which you are applying, do you have a valid driver’s license? *

Yes

No

If you are a minor, can you produce the work certificate necessary to obtain employment? *

Yes

No

N/A

Are you able, at the time of employment, to submit verification of your legal right to work in the U.S.? *

Verification and completion of Form 1-9 must be submitted no later than three (3) business days after date of hire.

Yes

No

Have you ever been convicted of any crime related to sex abuse or child abuse? *

Yes

No

Have you ever been convicted of a felony, which is substantially related to the functions, or qualifications of the position(s) for which you are applying? *

This question does NOT apply to convictions which have been expunged, sealed, pardoned or otherwise exonerated or eradicated. (A conviction record will not necessarily be a bar to employment.)

Yes

No

Name and Address of High School *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Did you graduate? *

Yes

No

High School Equivalency Diploma

Employer 1: Name & Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Employer 1: Phone Number

(###)

###

####

Employer 1: Supervisor Name

First Name

Last Name

Employer 2: Name & Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Employer 2: Phone Number

(###)

###

####

Employer 2: Supervisor Name

First Name

Last Name

Employer 3: Name & Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Employer 3: Phone Number

(###)

###

####

Employer 3: Supervisor Name

First Name

Last Name

Reference 1: Name *

First Name

Last Name

Reference 1: Phone Number *

(###)

###

####

Reference 2: Name *

First Name

Last Name

Reference 2: Phone Number *

(###)

###

####

Reference 3: Name *

First Name

Last Name

Reference 3: Phone Number *

(###)

###

####

Agreement *

I have read, understood, and accepted the terms of Compeer Rochester's Application Certification written above.

Today's Date *

MM

DD

YYYY