Form #S1000
EMPLOYMENT APPLICATION PART 1 – PRE-INTERVIEW
New York State (NYS) is an equal opportunity/affirmative action employer. NYS Law prohibits discrimination because of
age, race, creed, color, national origin, sexual orientation, military status, sex, disability, predisposing genetic
characteristics, marital status, domestic violence victim status, carrier status, gender identity or prior conviction records, or
prior arrests, youthful offender adjudications, or sealed records unless based upon a bona fide occupational qualification
or other exception.
If you are a person with a disability and wish to request that a reasonable accommodation be provided for you to
participate in a job interview, please contact the Bureau of Personnel at [Link]@[Link] or 518-473-
7936.
IDENTIFYING INFORMATION
Please read all instructions carefully. All pages of this application must be completed, and the application signed. If you
need additional space, please use the ADDITIONAL REMARKS section. Applicants may be required to complete
additional components of the Employment Application as directed by the hiring agency. After the interview process,
Applicants must complete either Part 2A of the New York State Employment Application, as directed by the appointing
agency.
Name: XXX/XX/
Last First MI SSN (last 4 digits only)
Current Mailing/Street Address:
NYS EMPLID (if assigned)
City State Zip Code
County of Residence: ( )
Area code/Home phone
Email Address:
Permanent Street Address (if different from above): ( )
Area code/Business phone
List any other names by which you have been known (including nicknames): ( )
Area code/Cell phone
APPLICANT INFORMATION
1. All candidates must be eligible for employment in the United States and maintain this eligibility throughout their
employment with NYS. Employment is contingent upon the provision of proof of the right to accept employment in the
United States.
a. Are you legally authorized to work in the United States? Yes No
b. Will you now, or in the future, require sponsorship for employment visa status
(e.g. for an H-1B Visa)? Yes No
c. If under age 18, can you provide a work permit? Yes No N/A
POSITIONS MAY REQUIRE TRAVEL AND/OR OPERATION OF A MOTOR VEHICLE OR HEAVY EQUIPMENT
2. Certain positions may require extensive travel within a designated area of assignment; to otherwise travel in areas
that may not be served by public transportation; to routinely operate a motor vehicle; and/or to routinely operate
heavy equipment requiring a specialized license.
For positions requiring operation of a motor vehicle or heavy equipment, appointees must possess a driver license
valid in NYS at the time of appointment and continuously thereafter. Candidates who do not possess a driver license
valid in NYS must be able to demonstrate their capacity to meet the transportation needs of the job at the time of
interview.
Name: _________________________________________________________________________________________________
January 2019 NYS Employment Application: Part 1 Pre-Interview Form #S1000 Page 1 of 5
If you are required to possess a driver license for the position you are applying for, please complete the following
questions:
a. Do you currently have a valid driver license that allows you to operate a motor vehicle
in New York State? Yes No
b. If yes, please select your license class: A B C D E Other (specify)
Licensing state: License number: Expiration date: / /
c. For Commercial Driver License (CDL) holders, please list your endorsements or restrictions:
POSITIONS MAY REQUIRE PROFESSIONAL LICENSURE OR CERTIFICATION
3. For some positions, professional licensure, registration, certification, or other authorization to practice a trade or
profession is required. Applicants claiming these credentials will be required to provide proof as a part of the screening
process. If you are required to possess such credentials for the position you are applying for, please complete the
following questions:
a. Name of Trade or Professional License/Certificate:
Type/specialty: Issued by:
License no.: Issue date: / / Expiration date: / /
Registration date: / / Registration expiration date: / /
b. Do you have any conditional limitations or restrictions on your ability to practice
under your professional license/certification/registration? Yes No N/A
c. Has your license/certification/registration ever been suspended or revoked? Yes No N/A
If yes to 3b or 3c, please specify in detail:
d. For teacher certification: Is your certification Initial, Provisional, Permanent or Professional? Please specify:
POTENTIAL FOR CONFLICT OF INTEREST
4. Please provide the names of any relative(s) employed by the agency with which you are seeking employment. For
the purposes of this application, a “relative” is defined as a person living in the same household; OR parents,
grandparents, spouse, siblings, children, aunts, uncles, nieces, nephews, or in-laws.
Relative Name: Relationship to you:
Check here if you have no relative(s) employed by the agency with which you are seeking employment.
5. If offered a position with this agency, will you also intern, volunteer or maintain employment concurrently
elsewhere? Yes No
Please note that if you intend to maintain other employment while employed by the hiring agency, that agency’s
approval to do so may be required. Applicants should inquire about their ability to maintain other employment at the time
of interview.
JOB INTERESTS AND EMPLOYMENT AVAILABILITY
6. Type of work or position desired:
7. Geographic work location(s) desired:
Name: _________________________________________________________________________________________________
January 2019 NYS Employment Application: Part 1 Pre-Interview Form #S1000 Page 2 of 5
8. Some positions require different work schedules. Please indicate which schedules you would be able to perform:
Hours Ability to work Schedule Ability to work Duration Ability to work
Shift work Yes No Saturday hours Yes No Permanent Yes No
Overtime Yes No Sunday hours Yes No Temporary Yes No
Full-time Yes No Seasonal Yes No
Part-time Yes No Summer only Yes No
Per diem Yes No Winter only Yes No
9. If offered a position with the hiring agency, when would you be available for work?
EDUCATION
Applicants will be required to provide proof of diploma and/or degrees claimed.
Courses of study
School Name/Location Credits Diploma or Degree received
(Major/Minor)
High school
Equivalency Issued by: Number:
program
Vocational or
Technical
Schools
Colleges or
Universities
Other training
or Military
schools
EMPLOYMENT AND EXPERIENCE
Please list all periods of employment*, beginning with the most recent, and include all prior experiences with any state or local
government. You must include all concurrent employment. Resumes will not be accepted in lieu of completing this section. If
you need extra space, please attach additional sheets. Agencies reserve the right to contact any or all of your employers to
verify the information provided.
Name of present or last employer:
Address: Date employed: / /
Supervisor’s name: To: / /
Supervisor’s title: Area code/Telephone: ( ) -
Your title and duties:
Reason(s) for leaving:
If this is your current employer, when may we contact them?
***************************************************************************************************************************************************************
Name: _________________________________________________________________________________________________
January 2019 NYS Employment Application: Part 1 Pre-Interview Form #S1000 Page 3 of 5
Name of present or last employer:
Address: Date employed: / /
Supervisor’s name: To: / /
Supervisor’s title: Area code/Telephone: ( ) -
Your title and duties:
Reason(s) for leaving:
If this is your current employer, when may we contact them?
***********************************************************************************************************************************************
Name of present or last employer:
Address: Date employed: / /
Supervisor’s name: To: / /
Supervisor’s title: Area code/Telephone: ( ) -
Your title and duties:
Reason(s) for leaving:
If this is your current employer, when may we contact them?
Additional Sheets Attached? Yes No
PROFESSIONAL REFERENCES
Name: Relationship:
Address: Telephone number: ( ) -
Email address:
*********************************************************************************************************************************************
Name: Relationship:
Address: Telephone number: ( ) -
Email address:
*********************************************************************************************************************************************
Name: Relationship:
Address: Telephone number: ( ) -
Email address:
*********************************************************************************************************************************************
Name: _________________________________________________________________________________________________
January 2019 NYS Employment Application: Part 1 Pre-Interview Form #S1000 Page 4 of 5
ADDITIONAL REMARKS
Additional Sheets Attached? Yes No
APPLICANT AFFIRMATION AND RELEASE AUTHORIZATION
I affirm that all statements made by me on this form, including attached papers, are true, complete and correct to the best of
my knowledge. I understand all statements made by me in connection with this application are subject to investigation and
verification and that falsification or omission of information is cause for the revocation of offer of employment or dismissal
from employment. I understand that knowingly making a false statement on this application or any attachment or supporting
document is punishable as a misdemeanor pursuant to Section 210.45 of the NYS Penal Law.
I hereby authorize any former or current employer, military records center, or school to provide the New York State
Department of Civil Service and/or the hiring authority any and all information necessary to reach an employment decision
including, but not limited to, information regarding my job duties, attendance, behavior, work habits, skills, abilities, claims,
liabilities, damage, and relationships with coworkers, customers or supervisors.
Signature: Date: / /
SUPPLEMENTAL INFORMATION FOR APPLICANTS
Applicants should retain a copy of this page for their records.
Additional Testing Required for Certain Positions: Physical/Medical examinations and/or drug and alcohol tests may be
required for certain positions. Failure to participate in any required examinations and/or tests will negatively affect your
employment eligibility and/or status.
Former State or Local Government Retirees: Section 150 of the Civil Service Law of New York State prohibits retired state
or local employees from being rehired by the state or a political subdivision and receives pension benefits while employed.
Applicants who are receiving service retirement benefits from New York State, Municipal or Political Subdivision Retirement
System must have approval under Section 211 or 212 of the Retirement and Social Security Law to protect their current
service benefits.
Post-Employment Restrictions: Post-employment restrictions apply to all State Officers and Employees subject to Public
Officers Law Section 73. They apply to part-time and seasonal employees, and apply equally regardless of the duration of
employment while with New York State. For the two-year period immediately following separation from State service, former
State Officers and Employees are prohibited from:
a. Appearing or practicing, regardless of compensation, before their former agency, and
b. Receiving compensation on behalf of a client in relation to a matter before their former agency.
State Officers and Employees may also be subject to a “reverse two-year bar” that requires State Officers and Employees to
recuse themselves from matters involving their former private sector employers for two years after entering State service.
The “lifetime bar” prohibits a former State Officer or Employee from providing services, regardless of compensation, and
from rendering services for compensation, in relation to any case, proceeding, application or transaction with respect to which
the former employee was directly concerned and in which he or she personally participated or which was under his or her
active consideration while in State service.
For positions requiring professional licensure and registration for appointment, continued employment in the position is
dependent upon maintaining current licensure and registration with New York State. I understand that loss of licensure and/or
current registration may result in termination from my employment.
Signature: Date: / /
PRIVACY STATEMENT
The information you are providing on this application is requested by the Office of Children and Family Services for the
purpose of determining eligibility for initial employment and continued employment and in administering employee benefit
programs. This information will be maintained by Human Resources, Bureau of Personnel. This information is collected and
maintained pursuant the Civil Service Law and Article 6-A of Public Officers Law. Failure to provide the requested information
may hinder your possible hiring and the subsequent administration of your employee benefits.
Name: _________________________________________________________________________________________________
January 2019 NYS Employment Application: Part 1 Pre-Interview Form #S1000 Page 5 of 5
