Form #S1000
New York State (NYS) is an equal opportunity/affirmative action employer. NYS Law prohibits discrimination because of age, race, creed, color, national origin, sexual orientation, military status, sex, disability, predisposing genetic characteristics, marital status, domestic violence victim status, carrier status, gender identity or prior conviction records, or prior arrests, youthful offender adjudications, or sealed records unless based upon a bona fide occupational qualification or other exception
If you are a person with a disability and wish to request that a reasonable accommodation be provided for you to participate in a job interview, please contact: NYS Department of Agriculture and Markets Human Resources Office at (518) 457-3216.


Please read all instructions carefully. All pages of this application must be completed, and the application signed. If you need additional space, please use the ADDITIONAL REMARKS section. Applicants may be required to complete additional components of the Employment Application as directed by the hiring agency.


All Applicants under consideration for a position with the hiring agency to whom they have applied are required to complete Questions 1-8 this Section, and to sign the Applicant Affirmation/Reference release statement.
Applicants for certain jobs will also be required to complete Questions 9-10, to agree to undergo a criminal background check, and agree to certain terms and conditions of employment. Please read the Instructions and Questions carefully before responding.

Instructions: In the event that you have a criminal history, it is important to note that answering “Yes” to a question below is not an automatic bar to employment.

Answering “Yes” may or may not preclude employment depending upon the nature of the criminal offense, its relationship to the position sought, and other factors that must be considered before employment may lawfully be denied based upon prior convictions.

If your response to any of the questions below is “Yes,” please provide an additional explanation and information in the ADDITIONAL REMARKS section. Each response will be reviewed on an individual basis in relation to the specific job for which you are applying. Failure to disclose a prior conviction that does not meet the criteria above may result in denial of employment based upon falsification of the employment application.

Applicants should answer “No” to the following questions if:
a. Your conviction (Felony, Misdemeanor, or Violation) was sealed by a court, or

b. The criminal action or proceeding was terminated in your favor, (e.g. was dismissed, you received an Adjournment in Contemplation of Dismissal and the adjournment period has elapsed, you were acquitted) or

c. The proceeding on the criminal offense resulted in a youthful offender adjudication or juvenile delinquency finding, or

d. After completing a treatment program, your plea to a Felony or Misdemeanor was withdrawn and you were resentenced to a violation or a felony or misdemeanor which was sealed by the court, or the completion of the program resulted in a dismissal of all charges by the court.


You must provide an explanation in the Additional Remarks section below for each “Yes” response you select.
1. Have you ever been found guilty of unprofessional conduct, professional misconduct, or negligence in any profession? *
2. Are charges now pending against you for unprofessional conduct or negligence in any profession? *
3. Have you ever surrendered any license in lieu of disciplinary procedures? *
4. Have you ever been discharged from employment except for lack of work, funds, disability, or medical condition? *
5. Have you ever resigned from any employment in lieu of disciplinary action or termination? *
6. Do you have an arrest or criminal accusation currently pending against you? *
7. Have you ever been convicted of a criminal offense (Felony or Misdemeanor)? *
8. Have you ever been dismissed from private employments because of habitually poor performance? *


I understand that I may be fingerprinted and that a complete Criminal Background Check (CBC) may be conducted.
Signature *


Questions 9-10 and the Background Investigation statement directly below apply only to Applicants seeking positions in certain agencies whose laws, rules and regulations require Applicants to undergo a more thorough Background Investigation.

You must provide an explanation in the Additional Remarks section below for each “Yes” response you select, and sign the attestation for this section.
9. Are you currently the subject of an indicated report of child abuse or maltreatment report on file with the New York Statewide Central Register of Child Abuse and Maltreatment?
10. Are you listed on the Staff Exclusion List* as an individual who is legally prohibited from providing care and services to a vulnerable person?
* defined in Article 11 of the New York State Social Services Law


I understand that I will be fingerprinted and that a complete Criminal Background Check (CBC) will be conducted. If required, I understand that my name will be checked against the Staff Exclusion List (SEL) maintained by the Justice Center for the Protection of People with Special Needs, and that I will be screened against the Statewide Central Register of Child Abuse and Maltreatment (SCR) prior to employment.
Signature *



I affirm that all statements made by me on this form, including attached papers, are true, complete and correct to the best of my knowledge. I understand all statements made by me in connection with this application are subject to investigation and verification and that falsification or omission of information is cause for the revocation of offer of employment or dismissal from employment. I understand that knowingly making a false statement on this application or any attachment or supporting document is punishable as a misdemeanor pursuant to Section 210.45 of the NYS Penal Law.

I hereby authorize any former or current employer, military records center, or school to provide the New York State Department of Civil Service and/or the hiring authority any and all information necessary to reach an employment decision including, but not limited to, information regarding my job duties, attendance, behavior, work habits, skills, abilities, claims, liabilities, damage, and relationships with coworkers, customers or supervisors.
Signature *
After clicking submit below, you will be given a refrence number and a option to print this document.
NYS Employment Application: Part 2 Post-Interview Detailed Form #S1000
July 2015