Employment Application

1Personal

2Skills, Training, Honors, Awards & Activities

3Education

4Employment

5Application Acknowledgement & Authorization

6Affirmative Action Information

7Veteran Status Information

Employment

Employer Name

First Last

Employer Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Most recent job title

Start Date

End Date

Supervisor name and contact information

Reason for leaving

Employer Name

First Last

Employer Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Most recent job title

Start Date

End Date

Supervisor name and contact information

Reason for leaving

Employer Name

First Last

Employer Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Most recent job title

Start Date

End Date

Supervisor name and contact information

Reason for leaving

Please explain all periods of unemployment

May we contact employers/ references at this time?(Required)

Yes

Provide (3) Business References (At least one must be a supervisor—None related to you)

Application Acknowledgement and Authorization

I certify that answers given herein are true and complete to the best of my knowledge. I also understand that false or misleading information given in my application, resume or interview(s) may result in a refusal to hire, or if hired, termination of employment. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. This application for employment shall be considered active for a period not to exceed 60 days. Any applicant wishing to be considered for employment beyond this time should inquire as to whether or not applications are being accepted at that time. All applications received for solicited positions will be kept on file for one year, for activation at the candidate’s or the organizations request as other positions become available. Under Massachusetts law, it is unlawful 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 liabilities. I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an “at will” nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this “at will” employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization. I also acknowledge that any offer of employment is contingent on appropriate licensing required to perform the duties of the position, the return of a background check (CORI plus any applicable to job) report which is acceptable for employment at Duffy Health Center, and the receipt of all necessary references. I understand, also, that I am required to abide by all rules and regulations of Duffy Health Center. I release all parties from liability for any damage that may result from complying with or attempting to comply with the authorization.(Required)

Type name in the above box

Date(Required)

Personal

Skills, Training, Honors, Awards & Activites

Education

Employment

Application Acknowledgement and Authorization

Duffy Health Center Voluntary Affirmative Action Information

Veteran Status Information