Human Technologies Corporation: Job Application

Behavioral Health Services – A Business of Human Technologies

Employment Application

Thank you for your recent interest in career opportunities with Human Technologies Corporation. To continue the employment process, complete the form below:

We are proud to be an Equal Opportunity Employer. People with disabilities are encouraged to apply.

HTC is a Tobacco Free Company.

There are positions within HTC subject to a background check. For details please speak with the Human Resources Department.

* indicates required field


Position Applying For *
2nd Choice
Date Available *
Referral Source *	Walk-in Advertisement - Specify: Employee - Specify: Relative - Specify: Government Agency (ie. VESID, OMRDD, etc) - Specify: Private Employment Agency - Specify: Other - Specify:
Resume Upload (optional)
Resume

Personal Information

Last Name *
First Name *
Middle Initial
Street Address *
City *
State *
Zip Code *
Home Phone
Alternate Phone
E-mail Address

If necessary, best time to call you at home is:	am pm
May we contact you at work?	Yes No
If yes, work number and best time to call:	Phone: Time: am pm
If you are under 18, can you furnish a work permit?
	Yes No
Have you filed an application here before? *
	Yes No
If yes, give date
Do you have family/friends who work for HTC? *
	Yes, Name(s): No
Have you ever been employed here before? *
	Yes No
If yes, when?	From: To:
Are you legally eligible for employment in the United States? *
	Yes No
Type of employment desired *	Full-Time Part-Time Temporary Seasonal Work Tryout
Are you on layoff and subject to recall? *
	Yes No
Will you relocate if the job requires it? *
	Yes No
Will you travel if the job requires it? *
	Yes No
Are you able to meet the attendance requirements of the position? *
	Yes No
Will you work overtime if required? *
	Yes No
Have you ever been bonded? *
	Yes No
Have you ever been convicted of a crime? * (Such conviction may be relevant if job related, but does not bar you from employment. Include traffic violations, misdemeanors, felonies, etc.)
	Yes No
If yes, please explain:
Driver's license number (if job related)	Number: State:

Employment History

Most recent/current Employer	Position	Address	Phone
Supervisor	Salary	Dates of Employment	Reason for Leaving
Job Duties
Employer	Position	Address	Phone
Supervisor	Salary	Dates of Employment	Reason for Leaving
Job Duties
Employer	Position	Address	Phone
Supervisor	Salary	Dates of Employment	Reason for Leaving
Job Duties

Education

	Name, City, State	Degree / Diploma Type	Date
High School
College
College
Graduate School
Business, Trade or Other

References - Give the names of professional references, not related to you, who may be contacted.

Name	Address	Phone	Business	Years Acquainted

May we request references from:
Your current employer? *	Yes No
Your former employer(s)? *	Yes No

Skills and Qualifications

Summarize any special training, skills, licenses, certificates and/or characteristics of yourself that may qualify you as being able to perform job-related functions for the position for which you are applying.
List special accomplishments, publications, awards (Exclude memberships which would reveal sex, race, religion, national origin, age, color, disability, or other protected status.)
List any additional information you would like us to consider.

Affirmative Action Plan Data

Applicants are treated during the hiring process without regard to: age, national origin, gender, religion, disability, sexual orientation, veteran status, marital status or any other legally protected status.
As a federal contractor, Human Technologies Corporation complies with all governmental regulations including Affirmative Action. HTC collects data for recordkeeping, reporting and other legal requirements only.
Completing this form is OPTIONAL. If you choose to fill in the requested information, it will not be part of the hiring process. It will be maintained in a confidential file separate from your application and/or personnel file. Information provided or not provided will have no effect on the hiring decision.
Position Applying	Date
Name
Date of Birth	Male Female
Ethnic Origin: (choose ONE)
American Indian/Alaskan Native
Asian & Asian American (Includes Pakistanis, Indians and Pacific Islander)
Asian & Asian American (Includes Pakistanis, Indians and Pacific Islander)
Hispanic (includes persons of Mexican, Puerto Rican, Central or South American or other Spanish origins or cultures)
White (Includes Arabians)
Other (please provide origin)
Veteran Status
Special Disabled Veteran)
Vietnam Era Veteran
Veteran (other)
Not a Veteran

It is understood and agreed upon that any misrepresentation by me on this application will be sufficient cause for cancellation of this application and/or separation from Human Technologies Corporation (HTC) service if I have been employed.

I give HTC the right to investigate all references and to secure additional information about me, if job-related. I hereby release from liability HTC and its representatives for seeking such information and all other persons, corporations or organizations for furnishing such information.

HTC is an Equal Opportunity Employer. HTC does not discriminate in employment and no question on this application is used for the purpose of limiting or excluding any applicant's consideration for employment on a basis prohibited by local, state or federal law.

This application is current for 1 year. At the conclusion of this time, if I have not heard from HTC and still wish to be considered for employment, it will be necessary to fill out a new application.

I understand that just as I am free to resign at any time, HTC reserves the right to terminate my employment at any time, with or without cause and without prior notice. I understand that no representative of HTC has the authority to make any assurances to the contrary.

I understand it is HTC's policy to hire qualified individuals with disabilities and to recognize the need for reasonable accommodations that may be required by the ADA.

I further agree to hold harmless those employers, educational institutions and individuals releasing information to HTC regarding my application for employment.

HTC is a Tobacco Free Company.

There are positions within HTC that are subject to a background check. For details please speak with the Human Resources Department.

I have applied for a position at the above indicated facility. I hereby authorize the release of any educational information and/or any information regarding my job performance to HTC and its affiliates.

My name: *

I agree * I do not agree

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2260 Dwyer Avenue Utica, NY 13501 (315) 724-9891