GENERAL INFORMATION AND POSITION DESIRED Type of work desired Are you legally permitted to work in the United States? Are you able to provide documentation demonstrating your legal ability to work in the United States? EDUCATION EMPLOYMENT RECORD
Please type NA if the questions do not apply to you.
Employer # 1 Address
Employer # 2 Address
Employer # 3 Address
Have you ever been involuntarily terminated from employment in any job, including but not limited to any of the positions identified in this application or your resume? PROFESSIONAL REFERENCES Reference # 1 Reference # 2 Reference # 3 DISCLOSURES
South Shore Autism Center is an equal employment opportunity employer and does not discriminate in hiring or employment on the basis of race, color, religious creed, national origin, sex, gender identity, sexual orientation, genetic information (Massachusetts General Laws c.151B defines “genetic information” as any written record or explanation of a genetic test of a person’s family history with regard to the presence, absence or variation of a gene. A genetic test is broadly defined as “any test of DNA, RNA, mitochondrial DNA, chromosome or proteins for the purpose of identifying genes or genetic abnormalities.”), ancestry, age, disability, military or veteran status or any other category protected by federal or state law. No question on this application is intended to secure information to be used for such discrimination. 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. This application will be given consideration, but its receipt does not imply that you will be employed. Please read carefully before signing. If you have any questions regarding this statement, please ask them as an employment interviewer before signing.
I authorize South Shore Autism Center to make inquiries regarding my work and educational history from any of my past employers and from educational institutions that I have attended. I release South Shore Autism Center, as well as my past employers and educational institutions, from any and all liability or damage for requesting and/or issuing this information. I acknowledge receipt of a separate statement that South Shore Autism Center may obtain a consumer, criminal, background or driving report on me for purposes of this employment application and, should I become employed by South Shore Autism Center, at any time during my employment South Shore Autism Center. I also understand that if (1) the Company has a drug and alcohol policy that provides for pre-employment testing as well as testing after employment; (2) consent to and compliance with such policy is a condition of my employment; and (3) continued employment is based on the successful passing of testing under such policy. I further understand that continued employment may be based on the successful passing of job-related physical examinations. I understand that if I am hired, I must provide proof of eligibility to work in the United States. If I do not provide such proof within three (3) days of my hire, I understand that South Shore Autism Center may terminate my employment. I understand that, if I am hired, my employment with South Shore Autism Center will be at will and may be terminated by South Shore Autism Center or me at any time and for any reason. I understand that no documents or statements of South Shore Autism Center will constitute a contract of employment that in any way limits South Shore Autism Center’s right to terminate employment at will. I further understand that the at-will nature of my employment cannot be changed except by a formal written contract signed by both the President of South Shore Autism Center and me. Without limiting in any way, the at-will status of my employment if I am hired, I understand that if any of the information I have provided on this application or any accompanying resume is untrue, South Shore Autism Center will immediately discharge me.
I hereby acknowledge that I have read the above statement and understand the same.