Job Application New | Challenge Workforce Solutions

Position Desired *

Name

First

Last

Middle Initial

Address

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Cell Phone

Email *

Email

Confirm Email

Please read and complete application thoroughly.

Incomplete application or failure to provide requested information may result in a delay in processing, which may affect consideration of your application.

Are you legally eligible to work in the United States?

Yes
No

(Proof of eligibility will be required upon offer of employment)

Are you over the age of 18 years?

Yes
No

If no, you will be required to provide working papers

Can you with or without reasonable accommodation perform the essential functions of this job?

Yes
No

(If you have any questions about the functions of the job, please ask the interviewer before answering this question.)

Have you ever applied or worked for Challenge before?

Yes
No

Have you ever been employed or worked as a contractor at Cornell University or Ithaca College?

Yes
No

Have you ever been convicted of a misdemeanor or a felony and do you have any pending criminal charges against you?

Yes
No

Do you have a valid driver’s license?

Yes
No

Have you ever been convicted of any moving violations in the past five years?

Yes
No

Is anyone related to you employed by Challenge?

yes
No

Have you ever been the perpetrator of a substantiated allegation of abuse?

Yes
No

On what date would you be available to work?

Are you interested in working?

Full Time
Part Time

Have you ever been or has a government agency proposed that you be excluded from participating in Medicare or Medicaid?

Yes
No

NO PERSON SHALL BE DENIED EMPLOYMENT ON THE BASIS OF ANY LEGALLY PROHIBITED DISCRIMINATION INVOLVING, BUT NOT LIMITED TO, SUCH FACTORS AS RACE, COLOR, RELIGION, NATIONAL OR ETHNIC ORIGIN, AGE, DISABILITY, MARITAL STATUS, SEXUAL ORIENTATION, GENDER IDENTITY OR EXPRESSION, GENETIC PREDISPOSITION OR CARRIER STATUS, DOMESTIC VIOLENCE VICTIM, AMNESTY OR MILITARY STATUS OR ANY OTHER STATUS UNDER LOCAL, STATE OR FEDERAL LAW

EDUCATION:

Name of High School and Address

High School Major Area of Study

# of Years of High School Completed

Graduated High School

Yes
No

High School Degree

College Information

Name of College and Address

College Major Area of Study

# of Years of College Completed

Graduated College

Yes
No

College Degree

Trade or Graduate Information

Name of Trade or Graduate School and Address

# of Years of Trade or Graduate Completed

Graduated Trade or Graduate School

Yes
No

Trade or Graduate School Major Area of Study

Trade or Graduate School Degree

TRAINING, LICENSES or SPECIAL ACCREDITATIONS:

Please list any specialized training, apprenticeships, licenses or skills, etc. (Do Not list any which reflect your race, color, religion, gender, national origin, age, disabilities or military status) (please attach a copy)

1. Name of Trade or Profession

1. License Number

1. Granted by (licencing agency)

1. City or State of

1. Specialty

1. Date License First Issued

1. Registered From:

1. Registered To:

2. Name of Training

2. Date Received

3. Other

3. Date Received

4. Other

4. Date Received

5. Other

5. Date Received

File Upload - alternatively, a copy of your certification will be required upon hire.

Click or drag a file to this area to upload.

WORK HISTORY:

START WITH PRESENT OR MOST RECENT EMPLOYER FIRST Please DO NOT reference resume – Incomplete applications may not be processed

Work History 1.

1. From:

1. To:

1. Company Name

1. Position

1. Describe Your Work

1. Address

1. Reason For Leaving

1. Name of Supervisor

1. Telephone

Work History 2.

2. From:

2. To:

2. Company Name

2. Position

2. Describe Your Work

2. Address

2. Reason For Leaving

2. Name of Supervisor

2. Telephone

Work History 3.

3. From:

3. To:

3. Company Name

3. Position

3. Describe Your Work

3. Address

3. Reason For Leaving

3. Name of Supervisor

3. Telephone

Please explain any gaps of more than 2 months in employment:

PROFESSIONAL REFERENCE CHECK:

References must be Manager, Supervisor or Human Resources Positions

Refference 1.

1. Reference Name

1. Employer

1. Address

Address Line 1

Address Line 2

City

State

Zip Code

1. Telephone Number:

1. Cell Phone (If available)

1. Date you were employed From:

1. Date you were employed To:

1. Position(s) Held:

Reference 2.

2. Reference Name

2. Employer

2. Address

Address Line 1

Address Line 2

City

State

Zip Code

2. Telephone Number:

2. Cell Phone (If available)

2. Date you were employed From:

2. Date you were employed To:

2. Position(s) Held:

Reference 3.

3. Reference Name

3. Employer

3. Address

Address Line 1

Address Line 2

City

State

Zip Code

3. Telephone Number:

3. Cell Phone (If available)

3. Date you were employed From:

3. Date you were employed To:

3. Position(s) Held:

Reference 4.

4. Reference Name

4. Employer

4. Address

Address Line 1

Address Line 2

City

State

Zip Code

4. Cell Phone (If available)

4. Date you were employed From:

4. Date you were employed To:

4. Position(s) Held:

PLEASE READ CAREFULLY BEFORE SIGNING

I certify that all information I have provided is true, complete and correct. I authorize Challenge (or its agents) to investigate and verify all statements contained on my employment application and/or resume and any other material or information that I have provided. I authorize any employer, school, and other individual or entity that has knowledge of me, or my records to release information to and communicate freely with Challenge. In consideration for Challenge’s review of my application for employment, I hereby release my individual, entity and Challenge from all claims of liabilities that might arise from the inquiry into or disclosure of such information, including claims under any federal, state, or local civil rights law and any claims for defamation or invasion of privacy. I suggest you contact the individuals listed for references. I understand Challenge representatives may secure references from individuals other than those listed. I understand that submission of an application does not guarantee employment. If I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice, and Challenge reserves the same right to terminate my employment at any time, with or without cause and without prior notice, except as required by law. This application does not constitute an agreement or contract for employment for a specified period or definite duration. I understand that the existence of a criminal background may affect my ability to perform certain jobs, and if offered a position, Challenge has the right to review my background and perform a criminal background check. The presence of a criminal conviction in my background will not necessarily disqualify me from employment. Challenge complies with New York State Correction Law Article 23-A which provides certain rights to people previously convicted of a criminal offense, and will make an employment decision based on the bona fide relationship between the requirements of the job to be performed and the nature of the criminal offense, and based on our need to protect the safety and welfare of the public and the people we serve. Challenge will provide me with a summary of my rights under this article if I so desire. If I am arrested for a criminal offense after I am employed by Challenge, I understand that Challenge may use that information, in accordance with Article 23-A, in deciding whether to continue my employment. In consideration for employment with Challenge, if employed, I agree to conform to the rules, regulations, policies and procedures of Challenge at all times and understand that such obedience is a condition of employment. I understand that due to the nature of Challenge business, confidentiality, attendance and punctuality are considered essential requirements of every job at Challenge and that poor attendance or tardiness will result in disciplinary action. I understand that if I enter information in my employment application that is false, incomplete, or misrepresents the truth in any respect, Challenge may deny my application or terminate my employment, whenever it is discovered. If you are submitting this form online, you will be asked to sign

Signature

Date / Time

Equal Opportunity Employment

“The following information is requested by the Federal Government in order to monitor compliance with Federal laws prohibiting discrimination against applicants seeking to participate in this program. You are not required to furnish this information, but are encouraged to do so. This information will not be used in evaluating your application or to discriminate against you in any way. However, if you choose not to furnish it, we are required to note the gender, race/national origin of the individual applicants on the basis of visual observation or surname."

Ethnicity:

Hispanic or latino
Not Hispanic or Latino

Gender:

Challenge provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, national or ethnic origin, age, disability, marital status, sexual orientation, gender identity or expression, genetic predisposition or carrier status, domestic violence survivor, amnesty or military status or any other status under local , state or federal law. In addition to federal law requirements, Challenge complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training. Challenge Workforce Solutions expressly prohibits any form of workplace harassment based on race, color, religion, gender, sexual orientation, gender identity or expression, national origin, age, genetic information, disability, or veteran status. Improper interference with the ability of Challenge Workforce Solution’s employees to perform their job duties may result in discipline up to and including discharge.

In addition to running 5 businesses, Challenge also provides assistance to people with disabilities and/or economic barriers in finding employment. Please complete this voluntary form if you are interested in being contacted by Challenge staff to see if you are eligible for our free job placement & job retention services. You may be qualified for help if you are on public assistance; or have a disability. All support services provided by Challenge are free of charge. Completion of this form is voluntary and will not affect the status of your application for employment with Challenge.

Check here if any of the following statements apply to you.

I or a member of my immediate family receives cash or rental assistance from the Department of Social Services.
I have some form of disability (physical, developmental, mental, or learning)
I receive Supplemental Nutrition Assistance Program (SNAP) benefits or have applied for benefits
I receive Social Security Benefits due to a disability
I was referred here by a rehabilitation agency approved by the state, an employment network under the Ticket to Work program, or the Department of Veterans Affairs.
I speak English as a second language
I am a Veteran

Name:

Address

Phone:

Email

This information will be kept strictly confidential. An Intake Specialist will contact you to discuss your case individually and determine eligibility.
Disclaimer:
*Our services at Challenge are absolutely free of charge and can assist you with you employment options through our many services and businesses within the community.

Email *