Transitions Job Application

We are an equal opportunity employer for all applicants without regard to age, race, creed, color, national origin, sexual orientation, military status, sex, disability, predisposing genetic characteristics, marital status, domestic violence victim status, or any other protected status under federal, state or local laws.



Please note: Certain positions require a satisfactory driving record for employment

Employment Experience

Start With Your present or most recent job. Do not omit any jobs.

Job 2
Job 3
Job 4

Other Related History

Please list below any prior or current experience as an employee, volunteer or provider with the New York State Office for People with Developmental Disabilities (OPWDD), any other state agency or any other human services provider. Also, list any other experience you have relevant to the position for which you are applying. Employment listed under Employment History need not be repeated here. Please provide the names, addresses and telephone numbers for references who can verify each experience.

Educational History

High School

Professional References

Please give the names of 3 persons, not related to you, whom you have known in a professional capacity for over a year. Do not list supervisors that you have listed in the previous employment section.

Reference 1
Reference 2
Reference 3

Applicant's Statement

I certify that answers given herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

This application for employment shall be considered active for a period of time not to exceed 6 months. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time. The applicant understands that neither this document or any offer of employment from any employer constitute an employment contract unless a specific document to that affect is executed by the employer and employee in writing. I understand that I will be required to undergo the following tests and pre-employment screening as a condition of my employment: drug testing, criminal background check, driver's license check, state central register check and lifting assessment. I authorize the employer, to conduct the above-mentioned evaluations and that my job offer is contingent on satisfactory results. I further understand that at the time of any such testing, I will be required to execute all forms of consent and release of liability as are usually and reasonable to such testing. Finally, I understand that the results of any such testing shall be made available to the employer. Please be advised that you will need to provide information, statements and fingerprints according to the requirements of the employer, OMH and OPWDD in order for a background check to be conducted through DCJS. Also you will have the right to obtain, review and seek correction of any information received in response to the criminal background check conducted by DCJS. I also understand that the employer may not employ anyone that has been convicted of Medicaid fraud, and employer is required by law to inquire with the Office of Medicaid Inspector General to ensure eligibility in the federally sponsored health care programs such as Medicare and/or Medicaid. Your signature below gives us permission to conduct a check using public exclusion lists. In the event of employment, I understand that false or misleading information given in my application or interview may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with his organization is of an “at will” nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time or without cause. It is further understood that this “at will” employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization.

I authorize this organization to use my name and photo in any company literature and/or promotional activities.


I give this organization the right to contact and obtain information from all references employers, educational institutions and to otherwise verify the accuracy of the information contained in this application. I hereby release from liability the employer and its representatives for seeking, gathering, and using such information and all other persons, corporations, or organizations for furnishing such information.

I have read and understand above statements.

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(Please note: Your application for employment will not be considered complete unless the following information on BOTH sides of this addendum are completed and you have signed and dated this form.)

Part A

Part B

(If the position for which you are applying requires driving responsibilities, please fill out the information below. If you are unsure, please ask, prior to completion.)

By my signature below, I certify that the information provided is true and correct. I also understand that false or misleading information given in my application or interview may result in discharge:

Please print the following information, as it appears on your Driver's License. This information is required to complete a driver's abstract of your driving record:

I hereby authorize Lexington, Fulton County ARC to secure an abstract of my driving record.