BUFFALO STATE COLLEGE

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					                                                                                                                           BUFFALO STATE COLLEGE
                                                                                                                          Human Resource Management
                                                                                                               Cleveland Hall 403, 1300 Elmwood Avenue
                                                                                                                                  Buffalo, NY 14222-1095
                                                                                                                                           (716) 878-4822
Employment Application                                                                                                    www.buffalostate.edu/offices/hr
Applicant Information

Full Name:                                                                                                                          Date:
                Last                                                     First                                   M.I.
Address:
                Street Address                                                                                   Apartment/Unit #


                City                                                                                             State                   ZIP Code
Home Phone:            (       )                                          Work Phone:         (       )
                                                                                                          st                   nd                     rd
Availability:              Full-Time     Part-Time           Shift Preferences:            none       1 (days)             2        (evenings)       3 (nights)

How did you learn of the opening?                    ad       campus posting             employee referral               web site            other

Are you a retired NYS public employee?                                                                                                           Yes         No
Are you contemplating retiring from a NYS public agency prior to accepting any job offer at Buffalo State?                                       Yes         No
Are you a citizen of the United States?                                                                                                          Yes         No
         If no, are you legally eligible for employment in the United States?                                                                    Yes         No
Do you have any felony or misdemeanor arrests that have not been fully adjudicated?*                                                             Yes         No

            If yes, please explain:

Except for minor traffic violations and adjudication as youthful offender, have you ever been convicted of a
criminal offense against the law?*                                                                                                               Yes          No

            If yes, please explain:

*A “yes” response to this question will not automatically disqualify an applicant from employment consideration. Each application will be evaluated
based on the nature of the crime, when it occurred, and the duties and responsibilities of the position for which you are being considered.


Position(s) Desired
Administrative Support:                Maintenance:            Skilled Trades:                                                           Other:
  Clerical                               Cleaner                                                    Painter                                 Nurse
  Secretarial                                                      Electrician                      Plumber/Steamfitter                     University Police
                                         Laborer                   Mason/Plasterer                  Sheet Metal                             Computer Operator
                                                                   Mechanic

Education

High School:                                                      Address:

From:                          To:                    Did you graduate?              Yes            No           Degree:

College:                                                          Address:

From:                          To:                    Did you graduate?              Yes            No           Degree:

Other:                                                            Address:

From:                          To:                    Did you graduate?              Yes            No           Degree:

Skills, Licenses, Certifications
List any licenses, certifications, skills (e.g., NYS driver’s license, commercial driver’s license, skilled trade apprenticeship, computer skills).
Employment History

Employer:                                                                                Phone:         (      )

Address:                                                                                        Supervisor:

Job Title:

Responsibilities:

From:                          To:                        Reason for Leaving:

May we contact your previous supervisor for a reference?                          Yes           No

Employer:                                                                                Phone:         (      )

Address:                                                                                        Supervisor:

Job Title:

Responsibilities:

From:                          To:                        Reason for Leaving:

May we contact your previous supervisor for a reference?                          Yes           No

Employer:                                                                                Phone:         (      )

Address:                                                                                        Supervisor:

Job Title:

Responsibilities:

From:                          To:                        Reason for Leaving:

May we contact your previous supervisor for a reference?                          Yes           No

Military Service

Have you ever served in any branch of the United States Armed Forces?                                Yes           No
If yes, was your discharge other than honorable?                                                     Yes           No

Applicant Certification

I voluntarily give Buffalo State College the right to make a thorough investigation of my past employment, agree to cooperate in such investigation,
and release from all liability or responsibility all persons, companies or corporations supplying such information. It is understood that my present
employer will not be contacted without my further consent.

I understand that if I am selected for a position for which a medical examination is required, I will be offered a conditional offer of employment
contingent upon satisfactory completion of required medical exam.

I certify that the information provided herein is true and correct. I authorize investigation of all statements contained in this application. If employed,
any material misstatement or omission of fact on this application may result in my dismissal.

Buffalo State College is an equal opportunity employer. It is the College’s policy to employ qualified applicants without regard to race, color, sex,
age, handicap, national origin, religion, veteran status, sexual orientation or preference.


Applicant Signature:                                                                                                Date:

                                     Return completed application to Human Resource Management, Cleveland Hall 403.

				
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