Employment Application

Application for Employment

Applicants for employment are considered without regard to race, color, religion, sex, marital status, national origin, age, or handicap. Also it is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability.

Position Applying for Desired Salary

Referral Source: Advertisement Friend Relative Walk – in Other
If other please specify

First Name
Last Name
Address
City
State	Zip Code
Telephone	-
Email Address

Are You Under 18? YES NO

If employed and under 18,
Can you furnish a work permit? YES NO

Have you filled an application here before? YES NO
If yes, give date

Have you ever been employed here before? YES NO
If yes, give date

Are you employed now? YES NO
May we contact your present employer? YES NO

Are you a U.S. citizen? YES NO
If no, do you possess a valid work permit? YES NO

(Proof of citizenship or immigration status may be required upon employment.)

On what date would you be available to work?

You are available to work Full Time Part Time Overtime

Are you on lay-off and subject to recall? YES NO

Can you travel if a job requires it? YES NO

AN EQUAL OPPORTUNITY EMPLOYER

Education and References

Name	City State	Major Course of Study	Years Completed: Circle	Date Completed	Diploma Or Degree	Scholasstic Average
High School or Preparatory	,		1 2 3 4
College	,		1 2 3 4
Specialized Training	,		1 2 3 4

Honors Received:

Are you a veteran of the U.S. Military Service? YES NO

If yes, branch

Please describe any special skills or training aquired while in the service.

Rate how well you speak, read, and / or write any foreign languages.
Specify Language (i.e., Spanish, French)

Speak	Fluent Good Fair
Read	Fluent Good Fair
Write	Fluent Good Fair

REFERENCES
Give name, address, and telephone number of three references who are not related to you and are not previous employers.

Reference 1 Name-Address-Telephone	Reference 2 Name-Address-Telephone	Reference 3 Name-Address-Telephone

EMPLOYMENT EXPERIENCE

Start with your present or last job. Include military service assignments and any verified work performed on a volunteer basis. Exclude organization names that indicate race, religion, sex, or national origin.

EMPLOYER 1

Dates Employed		Employer Name	Job Title
dd/mm/yyyy to	dd/mm/yyyy
		Employer Address	Supervisor Name& Phone
Hourly Rate/Salary		Work Performed:	Reason for Leaving:
Starting	Final

EMPLOYER 2

Dates Employed		Employer Name	Job Title
dd/mm/yyyy to	dd/mm/yyyy
		Employer Address	Supervisor Name& Phone
Hourly Rate/Salary		Work Performed:	Reason for Leaving:
Starting	Final

EMPLOYER 3

Dates Employed		Employer Name	Job Title
dd/mm/yyyy to	dd/mm/yyyy
		Employer Address	Supervisor Name& Phone
Hourly Rate/Salary		Work Performed:	Reason for Leaving:
Starting	Final

EMPLOYER 4

Dates Employed		Employer Name	Job Title
dd/mm/yyyy to	dd/mm/yyyy
		Employer Address	Supervisor Name& Phone
Hourly Rate/Salary		Work Performed:	Reason for Leaving:
Starting	Final

Special Skills and Qualifications
Summarize special skills and qualifications acquired from employment or other experience:

NOTICE TO APPLICANTS

United States law (immigration Reform And Control Act of 1986) forbids the company from hiring any person who is not a United States citizen or an alien who is specifically allowed by the U.S. government to work in the United States.

If you are not authorized to work in the United States please do not apply. We hire only U.S. citizens and those aliens who are permitted by the United States government to work in the United States.

No one that we hire will be allowed to work until:

They sign a sworn statement that they can legally work in the United States, and
They show us the original and give us a copy for our files of a birth certificate, social security card, driver’s license with photograph, photograph identification issued by the State, U.S. Passport, Certificate of Citizenship or Naturalization, resident alien card (“green card”) or other identification documents approved by the U.S. government.

Making a false oath or giving us false papers to get a job is punishable by jail and a possible fine.

Our application papers may be inspected by the U.S. Immigration Service and the U.S. Department of Labor.

SEALED RECORD NOTICE

Applicants having sealed conviction records on file with the Commission of Probation may answer “no record” to the following questions:

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, please explain

Have you ever been convicted of a felony? YES NO

If yes, please explain

BY SUBMITTING THIS FORM I understand the terms of this form and agree to the following:

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