MA Employment Application Form

Commonwealth of Massachusetts - Application for Employment

IMPORTANT

Instructions for completing the application form

1. Type or print clearly in black or blue ink.

2. Answer every question fully and accurately.

3. As an applicant for employment the Commonwealth will review, if applicable:

• Criminal Offender Record Information (C.O.R.I) and;
• The Central Registry of Child Abuse/Neglect reports maintained in accordance with M.G.L. Chapter 119, Section 51 B.

4. If an offer of employment is made to you, the Commonwealth may identify that it is contingent upon the results of a medical exam and/or a tax and background check.

5. FALSE OR MATERIALLY INACCURATE INFORMATION ON THIS APPLICATION WILL BE CAUSE FOR DISQUALIFICATION FOR EMPLOYMENT OR DISMISSAL AT ANY TIME AFTER EMPLOYMENT.

6. Read certification and releases carefully before signing.

7. Return completed application.

8. If you need an alternative version of this form, please contact the Agency Civil Rights Officer.

PERSONAL INFORMATION

First Name: Middle: Last Name:

Title: Home Telephone Number:

Mailing Address:

Home Address:

Business or Message Phone: E-Mail Address:

Are you authorized to work in the U.S. on an unrestricted basis? YES NO National ID (SS #) optional:

Are you over age 18? YES NO

Who referred you to us? Agency Employee Newspaper advertisement CEO Other

Have you been convicted of a felony? YES NO

EMPLOYMENT DESIRED

Position Applied For: Date you can start:

Name of State Agency Where Position Is Located:

Have you worked for the Commonwealth before? YES NO Starting salary desired:

Are you available for full time work? YES NO Are you available for part time work? YES NO

Have you reviewed the essential functions of the job as listed on the CEO or job posting? YES NO

EDUCATION

Additional education or training:

PROFESSIONAL REFERENCES

MILITARY SERVICE INFORMATION

Check all that apply to you: Veteran Disabled Veteran Viet Nam Era Veteran

Dates of service: to

Have you been certified by the State Office of Affirmative Action? YES NO

Certification #:

IMMEDIATE FAMILY WORKING IN MASSACHUSETTS STATE GOVERNMENT

EMPLOYMENT HISTORY

Are you employed now? Yes No

May we contact? Yes No

Dates Employed: To Salary Reason for Leaving

May we contact? Yes No

Dates Employed: To Salary Reason for Leaving

May we contact? Yes No

Dates Employed: To Salary Reason for Leaving

RELEASE AND CERTIFICATION

PLEASE READ BEFORE SIGNING

I understand that the foregoing will be verified in order to expedite my application for employment with the Commonwealth of Massachusetts. I hereby authorize the Commonwealth to conduct a full investigation into my background.

I authorize the Commonwealth to obtain my previous work records, employment records, character references and any other information concerning character, ability and habits and all other necessary information. Further I grant authority to the keeper of these records to release said records to the Commonwealth of Massachusetts for the purpose of making its hiring decision. I agree that the Commonwealth 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 employers 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 statements, omissions or answers made by me on this application can result in my immediate termination.

I understand that I will be required to provide approved documentation that verifies my right to work in the United States on my first day of employment. I have received the list of approved documents with this application.

I hereby acknowledge that I have read in full and understand the above statements and conditions of employment.

MISCELLANEOUS JOB-RELATED INFORMATION

Shift preferred: 1st (Days) 2nd (Evenings) 3rd (approx. 11:00pm–7:00am)

Are you available to work EVERY Saturday and Sunday? YES NO

Please prioritize your geographical preference(s) by numbering the boxes only in locations in Massachusetts in which you would be willing to work.

Greater Boston Central Northeast Southern Western

CERTIFICATIONS AND LICENSES

ENGLISH LANGUAGE

Describe your proficiency in the English Language: Simple conversation YES NO Simple Reading YES NO Read and speak fluently YES NO

LANGUAGE CAPABILITIES

List any language(s) other than English in which you are proficient including Sign Language and ability to read Braille.

IN CASE OF EMERGENCY, PLEASE NOTIFY

CRIMINAL OFFENDER RECORD INFORMATION (C.O.R.I)

I hereby acknowledge that I have read in full and understand the above statement.

PRE-EMPLOYMENT PHYSICAL & DRUG SCREENING NOTICE

I hereby acknowledge that I have read in full and understand the above statements.

IMMIGRATION REFORM AND CONTROL ACT REQUIREMENT

This section is informational and does not require a form field on the original page, but should be retained as reference text.

AFFIRMATIVE ACTION DATA RECORD

CONFIDENTIAL

Sex: Male Female

Race: White Black Hispanic Asian/Pacific Islander Native American

Vietnam Era Veteran: Person with a disability / Vietnam Era Veteran