CP Rochester is an Equal Opportunity employer complying with Federal and New York State laws, prohibiting discrimination in employment based on race, sex, color, religion, age, marital status, sexual orientation, national origin, disability, or military status

APPLICANT’S PERSONAL DATA

Name (Last, First, Middle)	Today's Date mm/dd/yyyy
Current Address (Street, PO Box) City	If you have lived at the above address less than one year please list previous address: Previous Address (Street, PO Box)
Current StateZip Email Address	Previous City StateZip
Have you previously been employed by CP Rochester? YesNo When? Capacity?	Have you previously submitted an employment application? YesNo When? Position?

APPLICANT’S EMPLOYMENT DATA

Position applying for:

Date of Application:
mm/dd/yyyy

Hours Available	SUN	MON	TUE	WED	THU	FRI	SAT
From
To

Type of position desired (select one)
Full Time Part Time
Substitute

Shifts Preferred
DaysEveningsOvernights

Salary Requirement

How did you hear about us?

Available Start Date

GENERAL INFORMATION

Have you ever been educated, licensed or worked under a different name? YesNo If yes, which name? If yes, which employer or educational institution?	Do you have any pending criminal charges in NY State or any other jurisdiction? YesNo If yes, please describe dates, crime jurisdiction? Conviction will not necessarily disqualify you from employment
Do you have any friends/relatives currently employed by CP? YesNo If yes, which name? Are you at least 18 years old? YesNo	Have you ever been convicted of a crime in NY State or any other jurisdiction YesNo If yes, please describe dates, crime jurisdiction? Conviction will not necessarily disqualify you from employment
Are you a citizen of the U.S. YesNo If your answer to the above question was NO, does your immigration status permit you to work? YesNo	If applying for a position that requires driving, do you have a valid and appropriate NYS drivers license? Do not answer if position applied for does not require job related driving. YesNo If out of state, which state?

EMPLOYMENT HISTORY

Please give accurate, complete, full-time and part-time employment record. Start with the present or most recent employer. Include military experience if applicable.
From: / To: / Mo. Yr.Mo. Yr.	Company Name
Starting Job Title Present (or last) Job Title	City, State Telephone
Immediate Supervisor's Name	Rate of Pay Per
Supervisor’s Job Title Reason for Leaving	Summarize Job Responsibilities and Duties
May we contact this employer now? YesNo If no, why not?

From: / To: / Mo. Yr.Mo. Yr.	Company Name
Starting Job Title Present (or last) Job Title	City, State Telephone
Immediate Supervisor's Name	Rate of Pay Per
Supervisor’s Job Title Reason for Leaving	Summarize Job Responsibilities and Duties
May we contact this employer now? YesNo If no, why not?

From: / To: / Mo. Yr.Mo. Yr.	Company Name
Starting Job Title Present (or last) Job Title	City, State Telephone
Immediate Supervisor's Name	Rate of Pay Per
Supervisor’s Job Title Reason for Leaving	Summarize Job Responsibilities and Duties
May we contact this employer now? YesNo If no, why not?

From: / To: / Mo. Yr.Mo. Yr.	Company Name
Starting Job Title Present (or last) Job Title	City, State Telephone
Immediate Supervisor's Name	Rate of Pay Per
Supervisor’s Job Title Reason for Leaving	Summarize Job Responsibilities and Duties
May we contact this employer now? YesNo If no, why not?

REFERENCES

List 5 references - 3 professional and 2 personal. Personal references must be individuals who are not related to you whom you have known for at least one year.

Name:
Relationship:
Telephone:
Email:
Personal Professional

EDUCATION

	Name of School (No Abbreviations)	Location City/State	Course of Study	Highest Grade Completed	Diploma/Degree Acquired
High School
College

Vocational/Technical
Other

APPLICANT AUTHORIZATION AND CONSENT
FOR RELEASE OF INFORMATION

I certify that the information herein is true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application for employment, as may be necessary in arriving at an employment decision. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge.

This application shall be considered for no more than 45 days. After that time applicants will be required to resubmit a completed application. The applicant further understands that if hired, such employment is not governed by any written or oral contract and is considered an "at-will" arrangement. This means that either party would be free to terminate the employment relationship at any time, for any reason without cause, so long as there is no violation of applicable federal state law.

I agree to the terms above.

Name

Maiden Name and/or Former Name

Social Security Number

Home Telephone Number

Cellular Telephone Number

Application Form

Employment