Employment Application

Personal Information

TO BE CONSIDERED FOR EMPLOYMENT, PLEASE COMPLETE THE FOLLOWING QUESTIONS COMPLETELY, EVEN IF ATTACHING A RESUME.

Position Applying for:*

Application Date:*

Last Name*

First Name*

Middle

Present Address:*

Street Address City State / Province / Region ZIP / Postal Code

Home Phone

Email*

Mobile Phone*

Have you ever worked for the Town of Marblehead, MA before?*

Yes

Have you ever worked under any other name? (If Yes,what name?)*

Yes

What name?

Do you currently have any relatives employed by the Town of Marblehead?*

Yes

If yes, who? (First/Last name and Relationship)

Do you have the legal right to be employed in the US?*

Yes

Have you ever been convicted of a felony?*

Yes

If yes, please explain

(Note: A conviction will not necessarily bar you from employment, each conviction will be judged on its own merits with respect to time, position, circumstance and seriousness.) An applicant with a sealed record on file with the Commissioner of Probation may answer “no record” with respect to an inquiry herein relative to prior arrests, criminal court appearances, or convictions. An applicant may also answer “no record” with respect to any inquiry relative to prior arrest, court appearances and adjudications in all cases of delinquency or as a child in need of services which did not result in a complaint being transferred to the superior court for criminal prosecution.

Mission Statement

Marblehead’s Mission statement: “To provide excellent services, at the level desired by citizens, taxpayers, and ratepayers, that ensure the health, safety, education, welfare, and quality of life of the community.”

Name/Location of School 1

Course of Study (List Major) 1

Graduated? 1

Yes

Type of Degree/Certificate 1

Name/Location of School 2

Course of Study (List Major) 2

Graduated? 2

Yes

Type of Degree/Certificate 2

Name/Location of School 3

Course of Study (List Major) 3

Graduated? 3

Yes

Type of Degree/Certificate 3

SPECIALIZED SKILLS AND KNOWLEDGE

List any Skills or knowledge that show your ability to perform the job for which you are applying, (such as typing/keyboard speed, computer languages or software programs, foreign languages, etc.)

EMPLOYMENT VERIFICATION

LIST YOUR LAST THREE EMPLOYERS FOR EMPLOYMENT VERIFICATION PURPOSES

Current/Last Employer’s Name, Address & Phone Number:

Supervisor’s Name/Phone Number:

Your Job Title:

Employed (Month/Year) From: To:

Reason for Leaving:

Prior Employer’s Name, Address & Phone Number:

Supervisor’s Name/Phone Number:

Your Job Title:

Employed (Month/Year) From: To:

Reason for Leaving:

Prior Employer’s Name, Address & Phone Number:

Supervisor’s Name/Phone Number:

Your Job Title:

Employed (Month/Year) From: To:

Reason for Leaving:

References

Name

Phone

Name

Phone

Name

Phone

Applicant's Certification and Agreement:

I certify that all the information provided on this application and attached resume (if applicable) is true and that any false statements or omissions may result in dismissal or ineligibility for employment. I understand the following: this employment application and any other organizational documents are not employment contracts and that I may leave or be terminated from the organization at any time with or without any reason or notice. Any statements made to the contrary are disavowed and should not be relied upon by any prospective or existing employee. I understand that completing this application creates no rights, express or implied, to employment with the organization. All offers of employment are conditional upon the receipt of additional information, including but not limited to, references and and a possible pre-employment health screening and drug test, as well as the successful completion of an introductory period which may be extended at the organization’s discretion. I grant permission to and release the organization harmless from any liability resulting from any investigation of the information provided on this application, my employment history, consumer credit history, criminal convictions, motor vehicle history, and/or Excluded Individuals/Entities checks. I also agree to release all individuals who supply references from any liability, which may arise from furnishing that information to the Town of Marblehead, MA..

Applicants Signature:*

Date*

It is unlawful to administer a lie detector as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability.

Personal Information

Mission Statement

EMPLOYMENT VERIFICATION

References

Applicant's Certification and Agreement:

Marblehead, Massachusetts

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