Employment
Contact Information
Name:
Street:
City:
State/Province:
Zip/Postal Code:
Phone:
Email:

Requested Information
Application for Employment
We are an equal opportunity and do not unlawfully discriminate against any applicant because of race, color, religion, sex, nation of origin, age, disability, sexual orientation, military status, or any other class protected by federal or state law.
Name (First, Last, MI):
Present address (Street, Town/City, State, Zip)
Phone number:
Cell number:
Email Address:
Are you legally authorized to work in the U.S.?
Are you 18 years or older?
Proof of work authorization is required by all employees within 72 hours of the start of employee's employment. You are required to supply your driver's license and social security card for proof of authorization required for I-9.
Position(s) for which you are applying?
Hourly rate desired:
Are you employed now?
If so, may we contact your present employer?
Have you ever worked at The Glenview before?
If so, when and what position?
Are you applying to work:
List all days/times available to work:
Education:
Name of School:
City and State:
Number of Years Completed:
Course of Study or Major:
Honors Received
Please indicate any skills you have that may be relevant to the position for which you are applying:
Describe any specialized study, job training, apprenticeships or extracurricular activities:
References (please furnish the names of three professional references, whom you have known for at least one year:
Name of most recent employer:
Address/City/State:
Phone #
Years Known:
Name of second most recent employer:
Address/City/State:
Phone #
Years Known:
Name of third most recent employer:
Address/City/State:
Phone #
Years Known:

Employment History
Most Recent Employer:
Address/City/State:
Telephone #
Supervisor:
Job Position Held:
Responsibilities:
Rate of Pay; starting and ending:
Starting date of employment:
Ending date of employment:
Reason for Leaving:
Name of second most recent employer:
Address/City/State:
Telephone #
Supervisor:
Job Position Held:
Responsibilities:
Rate of Pay; starting and ending:
Starting date of employment:
Ending date of employment:
Reason for Leaving:
Name of third most recent employer:
Address/City/State:
Telephone #
Supervisor:
Job Position Held:
Responsibilities:
Rate of Pay; starting and ending:
Starting date of employment:
Ending date of employment:
Reason for Leaving:
CRIMINAL RECORD: An applicant for employment with a sealed record on file with the Commissioner of Probation may answer "no record" with respect to any inquiry below relative to prior arrest, criminal court appearances, or convictions. An applicant for employment for employment may answer "no" if his or her criminal record consists only of one or more of the following: (1) an arrest, detention, or disposition regarding any violation of law in which no conviction resulted; or (2) a case of delinquency or a child in need of services, which does not result in a complaint transferred to the superior court for criminal prosecution.
1. Have you ever been convicted of a felony?
If so, list nature of offense, date of conviction and dates of incarceration associated therewith:
2. Have you ever been convicted of a misdemeanor?
If so, please list the nature of offense, date of conviction and dates of incarceration associated therewith. You may answer "No" if your criminal record consists of one nor more of the following: (1) Any misdemeanor conviction where the date of the conviction or completion of incarceration occurred 5 or more years before the date of this application, unless you were convicted of another offense during the past 5 years; or (2) a first conviction of drunkenness, simple assault, speeding, minor traffic offenses, disturbance of the peace or affray.
Note: A conviction record will not necessarily be a bar from employment.
I certify that my answers are true and complete to my knowledge. I authorize you to make such investigations and inquiries of my personal, employment, educational, financial, or medical history and other related matters as may be necessary for an employment decision. I hereby release employers, schools or persons from all liability when responding to inquiries in connection with my application.

In the event I am employed, I understand that false or misleading information given in my application or interviews may result in discharge.
Signature of applicant:
Date of signature:
 
   


248 Princeton St., North Chelmsford, MA 01863     TEL: 978-251-3591      FAX: 978-251-7144
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