CURRENT ADDRESS

PRIOR ADDRESS

AVAILABlLlTY

*Reasonable efforts will be made to accomodate sincerely held moral and ethical beliefs, (WI) religious beliefs and practices

JOB-RELATED SKILLS

NOTE: Do not fill out any part of this section you believe to be non-job related.

•  If the job requires, do you have the appropriate valid driver's license?

• Have you been given a job description or had the essential functions of the job explained to you? 

SECURlTY

Have you been convicted of a crime in the past seven years? If so, please describe in the boxes below. Applicant is not obligated to disclose any reference to a pre or post trial diversion program, any conviction which has been sealed, expunged or erased by the court, or, if in California, any marijuana related misdemeanor conviction entered more than two years prior to the date of this employment application. 

PREVIOUS EMPLOYERS 

PLEASE NOTE: Your application will not be considered unless every question in this section is answered. Since we will make every effort to contact previous employers, the correct telephone numbers of past employers are critical. Ask for a phone book or call information if necessary. FOR EMPLOYERS OUTSIDE THE U.S., A CURRENT FAX NUMBER IS MANDATORY.

In Massachusetts an applicant may include any verified work performed on a volunteer basis.  

MOST RECENT EMPLOYER 

DATES EMPLOYED 

SECOND MOST RECENT EMPLOYER

DATES EMPLOYED

THIRD MOST RECENT EMPLOYER 

DATES EMPLOYED

FOURTH MOST RECENT EMPLOYER

DATES EMPLOYED

REFERENCES

Include only individuals familiar with your work ability. Do not include relatives or names of supervisors listed above. 

EDUCATION

NOTE: Do not fill out any part of this section you believe to be non-job related. 

APPLICANT NOTE

This application form is intended for use in evaluating your qualifications for employment. This is not an employment contract. Please answer all appropriate questions completely and accurately. False or misleading statements during the interview and on this form are grounds for terminating the application process or, if discovered after employment, terminating employment. All qualified applicants will receive consideration without discrimination based on sex, marital status, race, color, age, creed, national origin, sexual orientation, military reserve membership, ancestry, religion, height, weight, use of a guide or support animal because of blindness, deafness or physical handicap, or the presence of disabilities. A conviction nill not necessarily bar an applicant from employment. Additional testing of job-related skills and for the presence of drugs in your body may be required prior to employment. After an offer of employment, and prior to reporting to work, you may be required to submit to a medical review. Depending on company policy and the needs of the job, you will be required to complete a medical history form and may be required to be examined by a medical professional designated by the company. 

"Under Maryland law, an employer may not require or demand, as a condition of employment, prospective employment, or continued employment, that an individual submit to or take a lie detector or similar test. An employer who violates this law is guilty of a misdemeanor and subject to a fine not exceeding $100."

"It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or coutinued employment. An employer who violates this law shall be subject to criminal penalties and civil liability." 

CERTIFICATION AND RELEASE 

I certify that I have read and understand the applicant note on this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief.  I understand that any false information, omissions or misrepresentations of facts called for in this application, whether on this document or not, may result in rejection of my application or discharge at any time during my employment I authorize the company and/or its agents, including consumer reporting bureaus, to verify any of this information. I release all former employers, persons, schools, companies and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I also understand that the use of illegal drugs is prohibited during employment. If company policy requires, I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment. 

COMMENTS