Lewis County Humane Society Application for Employment

Job Application Form

It is our policy to comply with all applicable state and federal laws prohibiting discrimination in employment based on race, age, sex, color, religion, national origin or other protected classifications. Please fill out each question fully and to the best of your abilities. If you've already supplied a resume through Indeed, you may skip the work experience and education.
Full Name*

First NameLast Name
DOB (must be 16)*

MonthDayYear
Date
Phone Number*

Area CodePhone Number
E-mail*
myemail@example.com
Present Address (ideally, we need someone within 20 miles of our shelter):*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Do you have a valid driver's license in NY? This position does require a license for transport of animals and is non-negotiable.*

YesNo
Driver's License Number*
XXX XX XXXX
Has your driver's license ever been suspended or revoked?*

YesNo
If yes, please explain:
Position Applied For*
Date you can start*

MonthDayYear
There are times when your shift may change and be extended to complete necessary work. This position will assist in covering for other employees who are ill, on vacation, or facing an emergency. Most requests will be given with advance notice, but some may be last-minute in cases of illness or emergency. Do you believe you have the flexibility in your schedule to accommodate these requests?*

YesNo
We are a 365 day a year operation, to include weekends and holidays. Shifts are currently 8am-2pm, and 4pm-7pm. We do try to accommodate individuals' schedules. Schedules are provided at the beginning of each month. Please let us know your availability:*

Monday - Morning ShiftMonday - Evening ShiftTuesday - Morning ShiftTuesday - Evening ShiftWednesday - Morning ShiftWednesday - Evening ShiftThursday - Morning ShiftThursday - Evening ShiftFriday - Morning ShiftFriday - Evening ShiftSaturday - Morning ShiftSaturday - Evening ShiftSunday - Morning ShiftSunday - Evening Shift
Animal Care Workers are required to work at least every other weekend. Are you able to meet this requirements?*

YesNo
Animal Care Workers handle both cats and dogs of all sizes, including possibly mean, feral cats and large, strong dogs. They must be able to physically restrain and manage these animals. They regularly lift heavy bags of food up to 50 lbs, and require general fitness for cleaning to include the ability to bend/kneel for extended periods. Are you able to meet all of these requirements?*

YesNo
Animal Care Workers must be comfortable working in: Loud environments, strong odors, emotionally difficult situations, and working around animal waste and cleaning chemicals. You must be calm under pressure. Are you able to meet all of these requirements?*

YesNo
Animal Care Workers are the first to work, and must be extremely punctual (you will be responsible for opening), reliable and able to follow protocols. Are you able to meet all of these requirements?*

YesNo
Animal Care Workers are expected to pass medications, both orally and by injection. You must be comfortable handling needles, and being able to follow protocols for passing meds. We will provide all necessary training. Are you able to meet all of these requirements?*

YesNo
You've gotten this far, congrats! Please tell us why you are interested in shelter animal care, specifically.*
Please state your previous employers from most recent to least recent.
Employed From

MonthDayYear
-
Employed To

MonthDayYear
Employer Name
Supervisor Name
Salary
Optional
Position
Reason for leaving
Employed From

MonthDayYear
-
Employed To

MonthDayYear
Employer Name
Supervisor Name
Salary
Optional
Position
Reason for leaving
Employed From

MonthDayYear
-
Employed To

MonthDayYear
Employer Name
Supervisor Name
Salary
Optional
Position
Reason for leaving
Have you ever been terminated?*

YesNo
If yes, please explain why:
Have you ever served in the military?

YesNo
Which branch and what were your dates of service?
Can you provide your DD214?

YesNo
Have you ever been convicted of a crime?*

YesNo
Classification

MisdemeanorFelony
If yes, please explain:

Enter your education history below

Rows	Years From/To	Graduated (Yes/No)	Courses
High School/GED
College
Trade
Special Classes

Any Additional Comments:
Please give the names of 3 people (other than family) whom you have known for at least 1 year.
First Reference
Full Name*

First NameLast Name
Phone Number*

Area CodePhone Number
How do you know this person?*
Years Known*
Second Reference
Full Name*

First NameLast Name
Phone Number*

Area CodePhone Number
How do you know this person?*
Years Known*
Third Reference
Full Name*

First NameLast Name
Phone Number*

Area CodePhone Number
How do you know this person?*
Years Known*
Electronic Signature*

First NameLast Name
Application Completed*

MonthDayYearHourMinutesAM/PM Option
An Equal Opportunity Employer

GENERAL AGREEMENT I understand that all offers of employment are conditioned on receipt of satisfactory responses to reference requests and provision of satisfactory proof of an applicant’s identity and legal authority to work in the United States. In consideration of my employment, I agree to conform to the rules and standards of The Lewis County Humane Society, as amended from time to time at the employer’s discretion.

AUTHORIZATION TO CHECK REFERENCES I hereby certify that the information contained in this application form is true and correct to the best of my knowledge and agree to have any of the information checked unless I have indicated to the contrary. I authorize the references listed above, as well as all other individuals whom the shelter may contact, to provide any and all information concerning my previous employment and any other pertinent information that they may have. I understand that any misinterpretation, falsification, or omission of material information on this application may result in my failure to receive an offer, or if I am hired, in my dismissal from employment.
I have read and agree to the above statement*

I agree
Should be Empty:

Job Application Form