Application for Employment

An Equal Opportunity Employer
APPLICATION
FOR EMPLOYMENT
(For use in Massachusetts)

It is the policy of The Arc of East Middlesex to provide employment, training, compensation, promotion and other conditions of employment based on qualifications, without regard to race, religion, national origin, sex, sexual preference, age, veteran status, Vietnam Era Veteran or being a member of the Reserves or National Guard, or disability. It is unlawful in MA to require or administer a lie detector test as a condition of employment or continued employment. Any employer who violates this law shall be subject to criminal penalties and civil liability.

Contact Information

*Name:

*Address:

*City:

*State:

*Zip:

*Phone No.:

In case of emergency contact:

Name:

Phone:

How did you hear about job opening?
Other (please Specify) Newspaper Job Announcement Friend
Other:

Are you under 18 years of age?

Yes No
if so, date of birth:

Were you ever employed by The Arc of East Middlesex?

Yes No

Are you employed now?
Yes
No

May we contact your present employer?
Yes
No

Are you proficient in speaking, writing, or reading a foreign language?
Yes
No

If yes, specify:

The Following Questions are mandatory for employment

Are you proficient in reading and writing English?

Yes No

Do you possess a valid U.S. drivers license?

Yes No

Will you have a personal insured vehicle available to you (on site) (n/a for Relief Staff)?

Yes No

Do you possess a High School Diploma/GED?

Yes No

Do you possess proper *identification for Immigration (I-9) requirements?
*(U.S. drivers license, ID card issued by federal or state government, U.S. Military card, birth certificate, social security card or a current employment authorization document issued by the INS)

Yes No

Job Interest

* Position or type of work Desired:
Date Available to begin work if accepted:

Shift Preferred:
Weekends
Night
Evening
Day

Seeking:
Temp.
Summer
Relief (per diem)
Regular
PT
FT

Days and Hours Available or Preferred:

Education

NAME

COURSE-DEGREE

High School

College

Graduate School

OTHER TRAINING/SKILLS i.e.: CPR, FA, CNA, EMT, MAP (MED. CERT.) Other vocational schools:

Sealed Record Notice:
An applicant for employment with a sealed record on file with the Commissioner of Probation may answer "no record" with respect to an inquiry herein relative to prior arrests, criminal court appearances or convictions. An applicant for employment with a sealed record on file with the Commissioner of Probation may answer "no record" to an inquiry herein relative to prior arrests or criminal court appearances. In addition, any applicant for employment may answer "no record" with respect to any inquiry relative to prior arrests, court appearances, and adjudications in all cases of delinquency or as a child in need of services which did not result in a complaint transferred to the superior court for criminal prosecution.

Within the past five years, have you been convicted of a misdemeanor? (Applicants may answer "no" with respect to a first conviction for drunkenness, simple assault, speeding, minor traffic violations, affray or disturbance of the peace.)

Yes
No
If Yes Explain:

Have you ever been convicted of a felony?

Yes
No
If Yes Explain:

Employment History

Please list all employment starting with present or most recent employer.
Account for all periods, including unemployment and service with the US Armed Forces. Also include relevant voluntary and/or part-time work experience.

Dates and Salary

Name, Address & Phone # of Employer

Immediate Supervisor's Name & Telephone

From (Month & Year):

To (Month & Year):

Last Salary:

Employer Name

Employer Address

Employer City/State/Zip

Employer Phone

Immediate Supervisor:

Telephone

Status:
Relief
Part Time
Full Time

Describe your principal duties or responsibilities:

Title or Position Held:

Reason for Leaving

May we contact this employer? Yes No

Dates and Salary

Name, Address & Phone # of Employer

Immediate Supervisor's Name & Telephone

From (Month & Year):

To (Month & Year):

Last Salary:

Employer Name

Employer Address

Employer City/State/Zip

Employer Phone

Immediate Supervisor:

Telephone

Status:
Relief
Part Time
Full Time

Describe your principal duties or responsibilities:

Title or Position Held:

Reason for Leaving

May we contact this employer? Yes No

Dates and Salary

Name, Address & Phone # of Employer

Immediate Supervisor's Name & Telephone

From (Month & Year):

To (Month & Year):

Last Salary:

Employer Name

Employer Address

Employer City/State/Zip

Employer Phone

Immediate Supervisor:

Telephone

Status:
Relief
Part Time
Full Time

Describe your principal duties or responsibilities:

Title or Position Held:

Reason for Leaving

May we contact this employer? Yes No

Employee Release And Privacy Statement

It is my understanding that this employment application, or the granting of an oral interview, does not represent a contract of employment or a promise of future benefits by this agency/organization. I understand and agree that if hired, my employment will be at-will in nature and may be terminated, with or without cause, at any time, by either my employer or myself. I also understand that this written statement supersedes any and all oral representations made by agents or representatives of this agency/organization.

AGREEMENT: I certify that the information on this application is true, complete and correct. I thereby authorize the investigation of my past employment, education and activities and I release from all liability all persons, companies and corporations supplying such information. I understand that false answers, statements or significant omissions made by me on this form shall be sufficient cause for denials of employment or discharge.

Applicant must initial:

*CLICK SUBMIT BUTTON TO ENTER APPLICATION WHEN FINISHED*