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161 Clear Road, Oriskany, NY 13424 | Phone: 1-800-500-0347 | Fax: 315-736-2285 | E-mail:

Check the box for the company that you are applying for:

We appreciate your interest in our organization and are sincerely interested in your background and qualifications. Please answer all questions as thoroughly as possible so we may review this information in consideration of employment with our organization. We are an Equal Opportunity Employer and will recruit, hire, promote and train in all jobs without regard to race, color, religion, age, disability, veteran status or non -job -related felony conviction records.

Personal Information
LastFirstMiddleHome Phone
Street AddressCitySTZipMobile Phone
Are you entitled to work in the United States? Yes No Are you 18 or older? Yes No Email:
Have you been convicted of a felony or been incarcerated in connection with a felony? Yes No If yes, please explain:
Military Service? Yes No Branch Are you a veteran? Yes No War
What position are you applying for? How did you hear about this position?
Preference for position that you are applying for ? Full Time Position Part Time Position Specified days if part-time Monday Tuesday Wednesday Thursday Friday
Expected Hourly Rate Expected Weekly Earnings Date Available
Are you currently employed? Yes No May we contact your current employer? Yes No
  Name/Location Last year Complete Month/Year Completed Degree Major or Emphasis
High School 1 2 3 4
College/University 1 2 3 4
Trade School 1 2 3 4
Other 1 2 3 4
List any applicable special skills,raining or proficiencies
Disclaimer By signing, I hereby certify that the above information, to the best of my knowledge,is correct. I understand that falsification of this information may prevent me from being hired or lead to my dismissal if hired. I also provide consent for former employers to be contacted regarding work records.
Prior Work Experience
Current or Most RecentPriorPrior

Yes No Yes No Yes No

Yes No Yes No Yes No
Personal References
Reference 1Reference 2Reference 3
Equal Employment Opportunity Data Collection Sheet
Completion of this form is optional and will in no way affect your application.

To help us comply with federal/state Equal Employment Epportunity reporting requirements, we ask that applicants complete the following questions. This pre-employment form is not part of the application for employment and is maintained in a confidential file separate from the application. Data is used for statistical purpose and to measure effectiveness of recruitment efforts.

Title of Job Applied for:

Date of Application:

Please check one appropriate box in each of the following categories:
GENDER: Male Female
RACE: White ( Not of Hispanic Origin) - All persons having origins in any of the original peoples of Europe, North Africa, or the Middle East.
Black ( Not of Hispanic Origin) - All persons having origins in any of the black racial groups in Africa.
Hispanic - All persons of Mexican, Puerto Rican, Cuban, Central or South America, or other Spanish culture or origin, regardless of race.
Asian or Pacific Islander - All person having origins in any of the original peoples of the Far East, Southeast Asia, the Indian Subcontinent, or the Pacific Islands. Origins include, for example: China, India, Japan, Korea, the Philippine Islands, Samoa, and Hawaii.
American Indian or Alaskan Native - All persons having origins in any of the original indigenous peoples of North America, and who maintain cultural identifi- cation through tribal affiliation or community recognition.

Please check any and all categories that apply to you:


1. A veteran who is entitled to compensation or who but for the receipt of military retired pay would be entitled to compensation under laws administered by the Department of Veteran Affairs for a disability.
a. R ated at 30 percent or more; or
b . Rated at 10 or 20 percent in the case of a veteran who has been determined under section 1506 of title 38, U.S.C., to have a serious emplo yment handicap; or
2. A person who was discharged or released from active duty because of a service-connected disability.

1. A person who served more than 180 days of active military, naval or air service, any part of which during the period of August 5, 1964 through May 7, 1975; and
2. Was discharged or released with other than a dishonorable discharge, or
3. Was discharged or released from active duty because of a service-connected disability.