EMPLOYMENT

APPLICATION

Distant Horizons NY, LLC is an Equal Opportunity employer and complies with all applicable Federal, State and local laws concerning discrimination in employment.  No question in this Application is intended to elicit information in violation of any law, nor will any information obtained in response to any question be used in violation of any such law.

            Distant Horizons NY complies with laws regarding reasonable accommodations for disabled applicants.  Applicants who require reasonable accommodations to participate in the interview process should contact the Human Resources Representative to arrange for such accommodations.

            Please read this Application carefully and print your response in ink.  You may submit a personal resume to Distant Horizons NY in addition to this Application; however, it is important for you to answer all questions and complete all sections of this Application.  We will retain your completed Application in our active files for ninety (90) days. 

Email Address:

Home Phone Number

 Cell Phone Number

 Date

 Other Names              Are you known under any other names or aliases

                                    (change of name, use of assumed name or nickname)

                                    that we need to know to check on your work record?

                                    If so, please explain.

2.  Prior Employment

            a) Have you ever been fired from a job?  If so, please explain. Yes    No

            b) Were you previously employed by Distant Horizons NY?  If yes, please give dates of employment and locations.

                Yes    No

             c) Please list the following information for your last three jobs: 

1. Prior Employer

Address

 Job Title/Dates Employed

 Area of Training/Special Skills

 Salary/Wage Reason for Leaving

 Name of Supervisor

2. Prior Employer

Address

 Job Title/Dates Employed

 Area of Training/Special Skills

 Salary/Wage Reason for Leaving

 Name of Supervisor

3. Prior Employer

Address

 Job Title/Dates Employed

 Area of Training/Special Skills

 Salary/Wage Reason for Leaving

 Name of Supervisor

3.   Prior Convictions for Any Sexual Offense

        Since reaching age 18, have you ever been convicted* of any sexual offense or indecent exposure, including felonies and misdemeanors,  which has not been annulled, expunged, or sealed by a court? Yes    No

If yes, please describe in full detail

* A conviction record will not automatically result in your disqualification for employment; felony and misdemeanor convictions will be considered only to the extent they relate to the job for which you have applied.  However, failure to disclose a conviction and/or mischaracterization of a conviction automatically will result in your ineligibility for employment and/or termination of employment (even if the conviction would not have barred your employment had it been properly disclosed)

4. Other Prior Convictions

                     Since reaching age 18, have you ever in the last ten (10) years been convicted of a crime, including felonies and misdemeanors, but excluding summary offenses* such as speeding tickets, which has not been annulled, expunged, or sealed by a court?  Yes    No

 If yes, please describe in full detail

* A conviction record will not automatically result in your disqualification for employment; felony and misdemeanor convictions will be considered only to the extent they relate to the job for which you have applied.  However, failure to disclose a conviction and/or mischaracterization of a conviction automatically will result in your ineligibility for employment and/or termination of employment (even if the conviction would not have barred your employment had it been properly disclosed)

5. Waiver to Conduct Background Check

                       I hereby authorize the company to thoroughly investigate my possible criminal background to verify the statements made above, and to determine my suitability for employment.

            If I am hired, I agree to submit to ongoing, periodic background investigations by the company to verify my continued suitability for employment.

I understand that, if I am otherwise qualified for employment,  Distant Horizons NY may extend to me a conditional offer of employment and such offer will be contingent upon my passing successfully a substance abuse screening test.  With regard to certain positions, the substance abuse screening test may be part of a more comprehensive health screening examination.

            I also understand that I will not be hired if I test positive for alcohol or illegal drugs, refuse to provide a specimen on the date and time required, refuse to consent to testing on the date and time required, or provide a false or tampered specimen.

            I further understand, if I become employed by Distant Horizons NY, I will be subject to Distant Horizons NY Policy on Alcohol and Substance Abuse.  If hired, I will be required to sign a Consent and Release Form and submit to periodic alcohol and drug testing if asked.

            I may obtain additional information about Distant Horizons NY Pre-Employment Drug Screening Policy and/or Distant Horizons NY Employee Alcohol and Drug Testing Policy from Distant Horizons NY General Counsel.                 

7. Waiver to Check References

                 I hereby authorize the company to thoroughly investigate my references, work record, education and other matters related to my suitability for employment.

 Further, I authorize all persons contacted by the company for a reference about my prior work performance to disclose to the company any and all letters, reports, reviews, opinions, observations, and other information related to my work, without giving me prior notice of such disclosure.

 In addition, I hereby release the company, my former employers, and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure.

            Your information will be sent to our Corporate office.  By submitting this application you are agreeing that all the information you submitted is true to the best of your knowledge.

             Type Name

             Date