First Name*
Last Name*
Email Address*
Phone*
Cover Letter
Who referred you to this position? Enter their first and last name here.
Do you have a valid driver's license?
No answer Yes No
What's your citizenship / employment eligibility?
No answer I am a U.S. Citizen/Permanent Resident Non-citizen allowed to work for any employer Non-citizen allowed to work for current employer Non-citizen seeking work authorization I am a Canadian Citizen/Permanent Resident Other
What's your highest level of education completed?*
No answer GED or Equivalent High School Some College College - Associates College - Bachelor of Arts College - Bachelor of Fine Arts College - Bachelor of Science College - Master of Arts College - Master of Science College - Master of Fine Arts College - Master of Business Administration College - Doctorate Medical Doctor Other
College or University
Are you 18 years of age or older?*
No answer Yes No
Earliest start date?*
Have you ever been convicted of a felony?*
No answer No Yes
If “Yes”, you have been convicted of a felony, please explain the circumstances around the conviction:*
References: Please enter names and contact information:*
Previous Employer 1: Name, Address and dates of employment. (If never worked, state N/A)*
Previous Employer 2: Name, Address and dates of employment
Previous Employer 3: Name, Address and dates of employment
List any special skills, qualifications or experiences relevant to the position for which you are applying.*
Are you between 16 and 21 years of age? (Please be advised, if under 18, you MUST have NYS work authorization?*
If applying for a Seasonal Lifeguard position, please indicate if you have the required certifications: Nassau County Lifeguard Certification and CPR/AED for Professional Rescuers and Health Care Providers.
Have you ever been employed by the Village of Hempstead? If yes, state dates and department.*
Do you have relatives working for the Village? If yes, state name and department:*
Are there any arrests currently pending against you? If yes, please explain:*
Do you reside in the Village of Hempstead?*
Have you ever been convicted of a crime?*
If yes to above, please explain:
To what position are you applying?*
Invitation for Job Applicants to Self-Identify as a U.S. Veteran
A “disabled veteran” is one of the following:
a veteran of the U.S. military, ground, naval or air service 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 Secretary of Veterans Affairs; or
a person who was discharged or released from active duty because of a service-connected disability.
A “recently separated veteran” means any veteran during the three-year period beginning on the date of such veteran's discharge or release from active duty in the U.S. military, ground, naval, or air service.
An “active duty wartime or campaign badge veteran” means a veteran who served on active duty in the U.S. military, ground, naval or air service during a war, or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense.
An “Armed forces service medal veteran” means a veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985.
Voluntary Self-Identification of Disability
Voluntary Self-Identification of Disability Form CC-305
Why are you being asked to complete this form?
How do you know if you have a disability?
