Work at Family Independence

Application for Employment

Family Independence is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, national origin, age, disability, handicap or veteran status.

Personal Data

Date

Name

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Home Phone

Business Phone

Are you legally authorized to work in the United States?YesNoNote: If you are hired, you will be required to submit proof of legal right to work in the United States.

Are you over 18 years of age?YesNo

If no, are you over 16 years of age?YesNo

Position / Availability

Indicate the position for which you are applying:

Type of employment desired:

Regular - Full TimeRegular - Part TimeTemporary - Full TimeTemporary - Part Time

Salary Desired

When could you start?

Have you ever worked for this Agency before?YesNo

If yes, please specify date, and department:

Have you ever applied for employment with this Agency before?YesNo

If yes, please specify date, and department:

Do you have any family members currently employed at the Agency?YesNo

If yes, please specify date, and department:

Employment History

List below the names of all your employers (you may list volunteer positions as well as paid positions, if you wish). List present employer or most recent employer first.

*Please note that a resume may be attached for this section providing all information is complete.

Employer

Title / Nature of work

Street Address

City

State/Province

ZIP / Postal Code

Country

Dates of employment - From:

Dates of employment - To:

Leave blank if you are presently employed.

Reason for leaving

Name / Title of immediate supervisor

Employer

Title / Nature of work

Street Address

City

State/Province

ZIP / Postal Code

Country

Dates of employment - From:

Dates of employment - To:

Leave blank if you are presently employed.

Reason for leaving

Name / Title of immediate supervisor

Employer

Title / Nature of work

Street Address

City

State/Province

ZIP / Postal Code

Country

Dates of employment - From:

Dates of employment - To:

Leave blank if you are presently employed.

Reason for leaving

Name / Title of immediate supervisor

Are you employed?YesNo

If yes, may we inquire of your present employer?YesNo

Do you have any commitments to another employer that might affect your employment with us?

Are you subject to any restrictive covenants from prior employment such as agreements to protect confidential or proprietary information or agreements not to compete? If so, please explain.

References

Provide the following information regarding 2 business and 1 personal reference:

(All references must be from people not related to you who have known you for longer than 1 year)

Business reference

Personal reference

Educational Data

High school

College

Graduate School

Trade/Business School:

Other:

Subjects of Special Study or Research Work:

Miscellaneous

Were you in the U.S. Armed Forces?YesNo

If yes, what Branch?

Dates of Duty - From:

Dates of Duty - To:

Rank at separation

Briefly describe your duties:

AGREEMENT:

(Please read the following statements carefully).

I certify that all information on this application and any other material provided by me is true and complete. I agree that falsified information, misrepresentations or omissions on this application, or any accompanying resume or other materials will disqualify me from consideration for employment and will be considered justification for dismissal whenever discovered.

Unless otherwise noted, I authorize this Agency or its agent to investigate and/or verify all information in this application, including contacting all persons, schools, current employer (if applicable), previous employers and other individuals or entities named herein (and those named on accompanying resume, if any). I hereby authorize my former employers and other third parties named on this application to release information pertaining to my work record, habits and performances. In doing so, I hereby release them and Family Independence, Inc. and its agents from all liability which may flow from the release of such information.

I understand that if I am hired my employment will be on an at-will basis, for no definite term. As such, I understand that I will enjoy the right to terminate my employment at any time, and that Family Independence, Inc. will similarly enjoy the right to terminate my employment, at any time, with or without cause. This status can only be modified by a written document setting forth such modification, signed by both me and an authorized representative of Family Independence, Inc.. I further acknowledge that I am expected to abide by all Agency rules, regulations, and policies, written or unwritten, but that such rules, regulations and policies do not create a contract between me and the Agency or otherwise restrict the right of either party to terminate the employment relationship.

Date

Note: 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.