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Application for Employment
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Steps
1.
Personal Information
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2.
Position
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3.
Education, Employment , Military history
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4.
References
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5.
Documents
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6.
Disclaimer & Signature
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7.
Release & Certification
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8.
Immigration Reform and Control Act Requirement
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9.
Pre-employment physical and drug screening notice
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Personal Information
Town of East Longmeadow
Equal Opportunity Employer / Affirmative Action Employer
Personal Information
First Name
*
Last Name
*
Middle initial
Address1
*
Address2
City
*
State
*
Zip
*
Phone Number
*
Email Address
*
Are you legally eligible to work in the United States? Proof of eligibility will be required upon hire.
*
Yes
No
Are you able to perform the essential functions of the position you are applying for, with or without reasonable accommodations?
*
Yes
No
If under the age of 18 can you furnish a work permit?
*
Yes
No
I am 18 years of age or older
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Position
Position information
Job title
*
Department
*
Type of employment desired
*
Full Time
Part Time
Seasonal
Weekly hours desired
Requested Salary $
*
Wage
*
-- Select One --
per hour
annually
Requested start date
*
Requested start date
How did you hear about the position?
*
Licenses, Registrations, Certifications
Examples: Teachers Certification, RN, CPA, Holsters License, CDL,etc.
Type
-- Select One --
License
Registration
Certification
Number
Date received
Date received
Expiration date
Expiration date
Licensing Authority
Type
-- Select One --
Licenses
Registration
Certification
Number
Date received
Date received
Expiration date
Expiration date
Licensing Authority
Driver's License information
Number
State
Class
Equipment Operators License
Yes
No
Class
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Education, Employment , Military history
Education information
High School
Address
Diploma/GED
College
Address
Degree
Other
Address
Degree
Military Service Information
Are you a Veteran?
Yes
No
From
From
To
To
Branch
Are you a member of any Armed Forces Reserve/National Guard Unit?
Please specify
Employment History
Describe all work experience in detail, beginning with your current or most recent job. Include internships, job related volunteer work, and any gaps in employment. All information in this section must be completed. Resumes and cover letters may be attached to provide additional information.
Company
Position
Supervisor
Phone Number
May we contact your previous supervisor for a reference?
Yes
No
Address
Responsibilities
Employed From - To (Date)
Company
Position
Supervisor
Phone Number
May we contact your previous supervisor for a reference?
Yes
No
Address
Responsibilities
Employed From - To (Date)
Company
Position
Supervisor
Phone Number
May we contact your previous supervisor for a reference?
Yes
No
Address
Responsibilities
Employed From - To (Date)
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References
Please list three professional references.
Full Name
*
Relationship
*
Company
*
Phone Number
*
Email Address
*
Full Name
*
Relationship
*
Company
*
Phone Number
*
Email Address
*
Full Name
*
Relationship
*
Company
*
Phone Number
*
Email Address
*
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Documents
Cover Letter
Resume
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Disclaimer & Signature
I certify that my answers are true and complete to the best of my knowledge and that intentional misrepresentations or omissions may be cause for the rejection of my application and that if hired I may be released from employment.
I understand that the company may require me to successfully complete a pre-employment drug and alcohol test and a background check as a condition of employment and that continued employment may be based on the successful completion of similar tests. By signing this document I am agreeing to release any and all records of employment including but not limited to my personnel file.
Your electronic signature below indicates your agreement with the following statements: By typing my name in the following box and clicking submit button I certify the above statements to be true and correct, to the best of my knowledge, and that this information can be used for the purpose of processing my employment application and information.
Applicant Signature
*
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Release & Certification
I understand that the foregoing will be verified in order to expedite my application for employment with the Town of East Longmeadow. I hereby authorize the town to conduct a full investigation into my background. I authorize the town to obtain my previous work records, character references and any other information concerning character, ability and habits and all other information the town deems necessary. Further, I grant the authority of the keeper of these records to release said records to the Town of East Longmeadow for the purpose of making its hiring decision. I agree that the town shall not be liable in any respect if a job offer is not extended, is withdrawn, or my employment is terminated because of false statement, omissions or answers made by me on this application. I agree that my previous employer shall not be liable with regard to any information provided by them in connection with this release. I certify under the pains and penalty of perjury that all statements made by me on this application are true and complete to the best of my knowledge and that I have withheld nothing, which, if disclosed, would affect this application unfavorably. I understand that any false statement, omissions or answers made by me on this application can result in my immediate termination. In compliance with the Immigration and Reform and Control Act of 1986, I understand that I will be required to provide approved documentation that verifies my right to work in the United States on or before my first day of employment. I have received the list of approved documents with this application. I understand that unless I attain permanent status pursuant to MGL Chapter 31, I am subjest to terms of a collective bargaining agreement, my employment will be at-will, which means that both the Town of East Longmeadow and I are free to terminate the employment relationship at any time for any non-statutorily prohibited reason or for no reason at all, with or without notice. I hereby acknowledge that I have read in full and understand the above statements and conditions of employment.
Applicant Signature
*
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Immigration Reform and Control Act Requirement
In compliance with the Immigration and Reform and Control Act of 1986, you will be required to provide approved documentation that verifies your right to work in the United States prior to beginning work here at this agency. Please be prepared to provide any of the Following documentation if you are offered and accept a position with us: List A - Any 1 (one) of the following documents that establish both identity and employment authorization. 1. U.S. Passport or U.S. Passport Card 2. Permanent Resident Card or Alien Registration Receipt Card (Form I-551) 3. Foreign passport that contains a temporary I-551 stamp or temporary I-551 printed notation on a machine readable immigrant visa 4. Other approved documentation as indicated on I-9 Form List B – Any 1 (one) of the following documents that establish identity in combination of any 1 (one) document from List C: 1. State issued driver’s license or photo ID 2. Photo ID by federal, state or local government 3. School ID with photograph 4. Other approved documentation as indicated on I-9 Form List C – Any 1 (one) of the following documents that establish employment authorization in combination of any 1 (one) document from List B: 1. Social Security Card 2. Birth certificate 3. Other approved documentation as indicated on I-9 Form
Criminal Offender Record Information (CORI)
If employed, I agree to abide by all rules and regulations of the Town of East Longmeadow. I understand if convicted of a felony, I will notify my supervisor immediately. I agree to furnish such additional information and complete such examination as may be required to complete an employment process and understand that this application for employment in no way obligates the town to employ me. I understand that the town will, if applicable, review the Criminal Offender Record Information (CORI) and the Central Registry of Child Abuse/Neglect reports in accordance with M.G.L., Chapter 119, Section 51B.
Applicant Signature
*
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Pre-employment physical and drug screening notice
If an offer of employment is made to you, the town may specify that it is contingent upon the results of a medical exam. I freely and voluntarily agree to submit to a pre-employment physical and/or drug screen, as it relates to the requirement of a specific job, as part of my pre-employment application to the Town of East Longmeadow. I understand that either refusal to submit to such screening or failure to qualify according to the minimum standards established by the town for this screening may disqualify me from further consideration for employment. Further, I understand that any positive drug test results will be communicated in a confidential manner. I hereby acknowledge that I have read in full and understand the above statements.
Applicant Signature
*
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