An Equal Opportunity Employer
APPLICATION FOR EMPLOYMENT
Position(s) applied for:
Date:
Name:
Last
First
Middle
Social Security Number:
Address:
Street
City
State
Zip
Phone:
Email:
Referral Source:
Advertisement
Employee
Relative
Agency
Walk-In
Internet
Other
If person, please specify:
Have you ever applied for employment with us?
No
Yes
- If yes, give date:
Have you ever been employed here before?
No
Yes
- If yes, give date:
Are you authorized under the Immigration and Reform Control Act to work in the United States?
No
Yes
Employment is subject to verification of applicant's eligibility for employment under laws related to visa status.
Are you at least 18 years of age?
No
Yes
Do you have a valid driver's license?
No
Yes
Criminal Office Record Inquiry (CORI)
As a part of our hiring process, successful applicants for most positions will be required to undergo a Criminal Office Record Inquiry. Any information obtained will be kept confidential and will not necessarily disqualify an applicant for employment.
Have you ever been convicted of a felony?
No
Yes
If yes, please explain:
Have you been convicted of any other offense against the law? - see below before answering.
No
Yes
If yes, please explain:
You are not required to furnish information for:
1-Any offense committed prior to your seventeenth (17) birthday, unless such offense was bound for trial in Superior Court,
2-A misdemeanor conviction for drunkenness, simple assault, speeding, minor traffic violations, affray, or disturbance of the peace,
3-A misdemeanor conviction which occurred more than five (5) years ago unless you have been convicted of any offense within the last five years; or
4-A misdemeanor conviction which resulted in a period of incarceration which ended more than five (5) years ago unless you have been convicted of any offense within the last five (5) years.
Education Background:
A. List last two (2) schools attended, starting with most recent.
B. List number of years completed.
C. Indicate degree or diploma earned.
D. Major and minor field of study (if applicable).
A. School
B. Years Completed
C. Degrees / Diploma
D. Major
E. Minor
Do you have a high school diploma or G.E.D.?
No
Yes
Professional References:
List name and telephone number of three business or work references not related to you.
Name
Relationship to Applicant
Telephone
Years Known
Reference statement:
An inability to obtain references from applicants considered for employment may lead to their disqualification. Applicants are encouraged to facilitate the reference process to the best of their ability.
List special accomplishments, publications, awards, including volunteer experience: (Exclude information which would reveal sex, race, religion, national origin, age, ancestry, handicap or other protected status.)
Complete the following: Why are you interested in employment with Alternatives? (Please be specific)
Employment History:
List your last three (3) employers, starting with the most recent, including military experience. Explain any gaps in employment in the comment section below.
Employer:
Name
Address
Telephone
Job Title:
Immediate Supervisor and Title:
Reason for Leaving:
May We Contact For Reference:
No
Yes
Employed From:
Employed To:
Starting Wage:
Per:
Hour
Week
Month
Year
Ending Wage:
Per:
Hour
Week
Month
Year
Summarize the nature of the work performed and job responsibilities:
Employer:
Name
Address
Telephone
Job Title:
Immediate Supervisor and Title:
Reason for Leaving:
May We Contact For Reference:
No
Yes
Employed From:
Employed To:
Starting Wage:
Per:
Hour
Week
Month
Year
Ending Wage:
Per:
Hour
Week
Month
Year
Summarize the nature of the work performed and job responsibilities:
Employer:
Name
Address
Telephone
Job Title:
Immediate Supervisor and Title:
Reason for Leaving:
May We Contact For Reference:
No
Yes
Employed From:
Employed To:
Starting Wage:
Per:
Hour
Week
Month
Year
Ending Wage:
Per:
Hour
Week
Month
Year
Summarize the nature of the work performed and job responsibilities:
Please list additional employment. Include dates, employer, and brief description of responsibilities:
I hereby give Alternatives the right to make a thorough investigation of my past employment, education, and activities and I release from all liability all persons, companies, and corporations supplying such information. I fully release and indemnify Alternatives against any liability, which might result from making such investigation. I certify that the information provided by me in this application is true. I understand that any false answers or misleading information or implications made by me in this application or other required documents shall be considered sufficient cause for denial of employment or discharge.
Additionally, I understand that nothing contained in this employment application or in the granting of an interview is intended to create an employment contract between Alternatives and myself for either employment or for the providing of any benefit. If an employment relationship is established, I understand that it will be on an at will basis and I have the right to terminate my employment at any time and that Alternatives retains a similar right.
If you do not understand any information given or questions asked in this application, please ask for an explanation.
By typing my name below I certify this to be my true identity. I understand that if granted an interview I will be required to verify my identity using photo identification. At that time, I agree to provide a handwritten signature in the space provided below.
Signature:
Date:
EQUAL OPPORTUNITY EMPLOYMENT/ AFFIRMATIVE ACTION POLICY STATEMENT
Alternatives Unlimited, Inc. is committed to providing equal employment opportunity to all without regard to race, color, religion, ethnic background, national origin, sexual orientation or age. The agency is also committed to equal opportunity for persons with a disability and veterans.
This agency will take affirmative action to ensure that all recruitment, employment, training, compensation, job classification, assignments, work conditions, promotions, employee treatment and all other terms, conditions and privileges of employment be conducted and applied in a manner which does not discriminate against any person on the basis of race, color, sex, religion, national origin, ethnic background, age, disability or veterans status.
An affirmative action plan is maintained and reviewed at least annually. Workforce/utilization analyses are prepared quarterly and an evaluation is conducted yearly to monitor progress and identify and eliminate barriers to equal employment opportunity.
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. Revised 12/02
Affirmative Action Program Applicant Information Form
Alternatives is an Equal Opportunity Employer. As required by law, we must record certain information to be made a part of our Affirmative Action Program.
Applicants for employment are also invited to participate in the Affirmative Action Program by reporting their status as handicapped, disabled veteran, veteran of the Vietnam era or other minority. In extending this invitation you are also advised that: (a) workers (applicants) are under no obligation to respond, but may do so in the future if they choose; (b) responses will remain confidential within the Human Resources Department; and (c) responses will be used only for the necessary information to include in our Affirmative Action Program. We are a company that values diversity. We actively encourage women and minorities to apply. Refusal to provide this information will have no bearing on your application and will not subject you to any adverse treatment.
Please complete the information requested below. For further explanation of terms used within this form, please see below. Thank you for your cooperation.
Section 1: General Applicant Information
Name:
Date:
Position(s) applied for:
Race or Ethnic Identity:
Hispanic or Latino
White (not Hispanic or Latino)
Black or African American (not Hispanic or Latino)
Native Hawaiian or Pacific Islander (not Hispanic or Latino)
Asian (not Hispanic or Latino)
American Indian or Alaskan Native (not Hispanic or Latino)
Two or More Races (not Hispanic or Latino)
I Do Not Wish To Self Identify
Gender:
I Do Not Wish To Self Identify
Male
Female
Veteran Status:
I Do Not Wish To Self Identify
None
Vietnam Era Veteran
Special Disabled Veteran
Other Eligible Veteran
Other Individual With Disabilities:
I Do Not Wish To Self Identify
No
Yes
Signature:
