Application Form

Position applied for:


Salary expectations
email address:
Are you 18 years of age or older?
Are there any days, shifts, or hours you will not work?
If yes, please explain:
Will you work overtime if required?
When will you be able to start work?
Have you ever been convicted of a crime of any nature?

Note: Answering “yes” does not automatically exclude you from further consideration for the position. All successful applicants must complete a criminal background check with the NewYork State Office of People with Developmental Disabilities.

If yes, please provide details.
How did you learn of Camphill Village?
If this is a referral, who referred you?
Have you ever applied to or worked for Camphill Village before?
If yes, please provide dates
Are you legally authorized to work in the United States?

Note: The Federal Immigration and Reform and Control Act of 1986 requires that a DHS Employment Eligibility Verification “Form I-9” be completed for every new hire and that within 3 business days of beginning work every new hire must present to the employer documentation establishing his/her identity and authorization to work. This federal requirement must be satisfied as a condition of employment.


(Answer only if driving is a requirement of the job for which you are applying.)

Do you have a valid driver's license?
License No.
Have you had any tickets? If so, please explain below.
If yes, please explain.


Please select the levels of education you have completed.
If you did not complete these levels, but earned partial credit, please indicate the educational institution you received credits from, and how many.
What subjects did you major or minor in?
Please indicate what, if any, licenses, certifications, or training you have.
Please list your degrees (e.g. Bachelor of arts in English, etc.)


Please complete for all full-time or part-time employment beginning with most recent employer. You may include as part of your employment history any verified work performed on a volunteer basis. All applicants should start with their most recent job, include active military assignments and voluntary employment and provide ten (10) years of history. You must explain any gaps in your employment history. (You may wish to attach a resume.)

Company #1
Company #1 Name
Company #1 info
Reason for leaving Company #1
Please state job titles and describe duties at Company #1
Company #2
Company #2 Name
Company #2 info
Reason for leaving Company #2
Please state job titles and describe duties at Company #2
Company #3
Company #3 Name
Company #3 info
Reason for leaving Company #3
Please state job titles and describe duties at Company #3
Company #4
Company #4 Name
Company #4 info
Reason for leaving Company #4
Please state job titles and describe duties at Company #4
Employment Other
Please explain any gaps in your employment history.
Have you ever been discharged or forced to resign?
If you answered yes, please explain.
Have you signed any non-competition or non-solicitation agreement with any other employer that might restrict you from working for Camphill Village (you may be required to furnish a copy of the agreement)?
If yes, please explain below.


Please list three persons not related to you who know your qualifications.

Reference #1
Reference #1
Reference #1 Phone:
Reference #2
Reference #2
Reference #2 Phone:
Reference #3
Reference #3
Reference #3 Phone:


Complete only if you served in the military.

Branch of Service:
Number of years/months of Service:
Rank at Discharge:
Date of Discharge:
Reason for leaving military service:
Describe any military skills, training or experience you believe are relevant to the job you applied for:

Applicant's Acknowledgment

I certify that the answers given herein are true and complete to the best of my knowledge. I understand that any misrepresentations, omissions of facts or incomplete answers in any application document may disqualify me from further consideration for employment. I further understand that, if employed, any misrepresentations or omissions of facts in any application document may be cause for my dismissal at any time without prior notice.

I consent to and authorize Camphill Village USA, Inc. to contact my former employers, references, and any and all other persons and organizations for information bearing upon my qualifications for employment. I further authorize the listed employers, schools and personal references to give Camphill Village USA, Inc. (without further notice to me) any and all information about my previous employment and education, along with any other pertinent information they may have and hereby waive any actions which I may have against either party(ies) for providing a good faith reference.

I understand that any job offer extended to me will be contingent upon the successful completion of any required criminal background check.

I understand that applicants for certain positions may be required to qualify for employment based on additional employment criteria. For example, I may be required to take job-related tests; take a driver’s examination; submit to a background investigation or take a pre-employment drug test. If I am offered employment or start work before any required test is completed, my employment is contingent on a satisfactory result on all required tests. I authorize the release of any background check results and of any drug/alcohol test to any state or federal authority requesting such information and in response to a valid subpoena or other legal document.

I further understand that, if hired, my employment is for no definite period of time and that either Camphill Village or I may terminate our relationship at will at any time, without notice or any reason, and that this employment application does not constitute an employment contract.

Signature of applicant (please type your name).

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