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APPLICANT INFORMATION Name: _____________________________________ _____________________________ ____________ (Last) (First) (Middle Initial) ADDRESS: ______________________________________________________________________________ (Number) (Street) (Borough) (Zip Code) SOCIAL SECURITY : ___________ - _______ - ___________ ARE YOU ELIGIBLE FOR EMPLOYMENT IN THE U.S. Yes No WHAT POSITION ARE YOU SEEKING HOW SOON ARE YOU AVAILABLE TO WORK ____PHYSICAL THERAPIST___________ SALARY PREFERRED: BOROUGHS PREFERRED: Per UFT Contract____ SOURCE OF REFERENCE: Posting _Immediately__/ ___________/ __________ Newspaper Other CIVIL SERVICE LIST______ _____________________________________________ HOME PHONE : ( ) __________ - ____________ WORK PHONE : ( ) __________ - ____________ HAVE YOU EVER BEEN CONVICTED OF A CRIME OR ARE ANY CRIMINAL CHARGES PENDING FOR ANY OFFENSE (NOT INCLUDING TRAFFIC VIOLATIONS) Yes No If Yes, please explain: ____________________________________________ ________________________________________________________________________________________ FAILURE TO ANSWER ALL QUESTIONS REGARDING CONVICTIONS AND/OR PENDING CRIMINAL CHARGES COULD LEAD TO AUTOMATIC DISMISSAL..