* Required

Habilitation Employment Application

*Full Name :

*Date :

*Address :

*City :

*State :

*Zipcode :

*Phone Number :

*Email :

If applying to work with someone specific, their name :

*Are you legally eligible for employment in the United States? : Yes
No

*Are you over 18 years old? : Yes
No

*Can you travel, as required by this position? : Yes
No

*Do you have a valid driver's license? : Yes
No

*Highest Level of Education : GED
Associates
Bachelors
Masters

Please list any additional training or experience you have that is applicable to this position (click and drag bottom right of box to enlarge) :

Number of hours you are interested in working per week:

Applicant's Statement :

I certify that the information given above is true and complete, and I understand that misrepresentation and/or withholding of information will result in the rejection of this application or my discharge if discovered after employment begins.

I authorize the Southern Tier Independence Center (STIC) to make inquiries regarding my history and character of prior employers and educational institutions, references, among others, and hereby release employers, educational institutions, or individuals from all liability in responding to inquiries in connection with my application and release STIC from all liability with respect to such inquiries.

I understand that if employed by STIC that I will be an employee “at will” and I acknowledge that there is no specified length of employment and that this application does not constitute an agreement or contract for employment.

I understand that it is the policy of this organization not to refuse to hire or otherwise discriminate against a qualified individual with a disability because of that person’s need for a reasonable accommodation as required by ADA. I also understand that if I am offered employment, I will be required to successfully pass multiple background checks.
I will be required to provide satisfactory proof of identity and legal work authorization. Failure to submit such proof within the required time shall result in immediate termination of employment.

I represent and warrant that I have read and fully understand the foregoing, and that I seek employment under these conditions.

Please copy and paste your resume into the text box below :

By clicking "submit", you hereby agree to the Applicant's Statement as previously described in this application.(Once you see a white screen, your form has been submitted.)