Employment

Application

• Positions(s) applied for

• Date

• How did you find out about this job? NewspaperEmployeeWalk-inRelative
  Other

• Why are you seeking a new job at this time?

Applicant Information

• First Name

• Middle

• Last

• Street Address

• Social Security No.

• City/State/Zip

• Phone

• Email

• If hired, do you have a reliable means of transportation to get to work? YesNo
  Describe

• Are you at least 18 years old? YesNo

• If you are under 18 years of age, can you furnish a work permit? YesNo

• If the job you are applying for requires driving: enter your Driver’s license No.

• License State

• License Expiration Date

• Are you legally eligible or employment in the U.S.? (Proof of U.S. citizenship or immigration status is required if hired.)
  YesNo

• Have you been convicted of a crime? (Massachusetts applicants should not include misdemeanor convictions; California applicants should not include marijuana-related convictions that occurred more than 2 years prior to the applications date.) YesNo

• If yes, state the nature of the offense and disposition o the case. Include dates and places. (NOTE: The existence of a criminal record does not constitute an automatic bar to employment.)

• Are you a veteran? YesNo

• If yes, give dates of service: From:
  To:

• List any special skills or training:

Employment Information

• Are you seeking full time, part time or temporary employment? —Please choose an option—full timepart timetemporary

• What hours and shift(s) would you prefer to work?

• List times you are not available to work?

• Are you willing to work overtime? YesNo

• Weekends? YesNo

• Holidays? YesNo

• Are you currently employed? YesNo

• If hired, when would you be able to start?

• Have you ever worked for this organization before? YesNo

• If yes, name used:

• List any friends or relatives employed by this company:

• Have you ever been discharged or ask to resign from any position? YesNo

• If yes, please describe:

• If applicable, please refer to the attached job description for the position for which you are applying. Are you able to perform all these tasks with or without reasonable accommodation? YesNo

• Please describe which tasks, if any, you will need accommodation to perform and explain what type of accommodation you will need:
  

• Please describe:

• Education (select highest level achieved)
  Elementary: 12345678
  Secondary: 9101112G.E.D.
  College:12345678

• Name of Elementary School:

• Location of Elementary School:

• Name of Secondary School:

• Location of Secondary School:

• If in high school, are you enrolled in a recognized co-op program? YesNo

• If yes, identify program and school:

• Name of College:

• Location of College

• Degree & Major

• Minor

Work History (Please begin with most recent)

• Company 1

• Phone No. with Area Code

• Address

• City/State/Zip

• Dates of Employment: From:
  To:

• Salary: Beginning:
  Ending:

• Job Title:

• Supervisor’s Name & Title:

• Describe duties briefly:

• Specific reason for leaving:

• Company 2

• Phone No. with Area Code

• Address

• City/State/Zip

• Dates of Employment: From:
  To:

• Salary: Beginning:
  Ending:

• Job Title:

• Supervisor’s Name & Title:

• Describe duties briefly:

• Specific reason for leaving:

• Company 3

• Phone No. with Area Code

• Address

• City/State/Zip

• Dates of Employment: From:
  To:

• Salary: Beginning:
  Ending:

• Job Title:

• Supervisor’s Name & Title:

• Describe duties briefly:

• Specific reason for leaving:

• Company 4

• Phone No. with Area Code

• Address

• City/State/Zip

• Dates of Employment: From:
  To:

• Salary: Beginning:
  Ending:

• Job Title:

• Supervisor’s Name & Title:

• Describe duties briefly:

• Specific reason for leaving:

• For reference purposes: Have you worked for any of these organizations or attended school under a different name? YesNo

• If yes, give name and organizations(s)

• May we contact the employers listed above? YesNo

• If not, list the employers you do not wish us to contact and why: