Town of Dudley

71 West Main St. #30, Ste. 307

Dudley, MA 01571

508-949-8011

 

Application for Employment

 

Instructions: Please print and complete all necessary information. You may be asked to provide additional information on another form. Sign and date the application.

 

This application will be kept on file for one year. It is to your advantage to periodically check to keep it current and active.

 

Applicants for employment are considered without regard to race, color, religion, sex, marital status, national origin, age or disability. Also 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.

 

Date of Application ___________________________

 

 

Position(s) applied for _________________________________________________________________________________________

 

 

Name ______________________________________________________________________________________________________

                        LAST                                                                                                              FIRST                                                              MIDDLE

 

Address ____________________________________________________________________________________________________

                                                NUMBER                               STREET                                                                                  CITY                                                                STATE                                         ZIP CODE

 

Phone Number________________________________________  Social Security Number: __________________________________

 

Are you under 18?      Yes      No          If you are under 18, can you furnish a work permit?        Yes          No

 

Do you have a valid MA CDL and Hydraulic driver’s license for backhoes and loaders? ____________________________________

 

Where did you hear of the vacancy? _____________________________________________________________________________

 

Have you applied to the Town of Dudley before?  Yes      No          If yes, give date _____________________________________

 

Were you employed by the Town of Dudley before?  Yes      No    If yes, date & position_________________________________

 

Are you employed now?  Yes      No            May we contact your present employer?  Yes      No

 

Are you a United States citizen?  Yes     No          If no, do you possess a valid work permit?  Yes     No

(Proof of citizenship or immigration status is required upon employment)

 

Date available for work ___________   Available to work    Full-time    Part-time    Temporary     Overtime

 

Are you on layoff and subject to recall?  Yes      No

 

Can you travel if the position requires it?  Yes    No

 

Special training or skills: (computer skills, machine operation, etc.) that would benefit you in the job for which you are applying:

 

___________________________________________________________________________________________________________

 

___________________________________________________________________________________________________________

 

 


 Have you ever been in the Armed Forces?  Yes      No          If yes, branch _____________________________________________

 

Are you currently a member of the Reserves or National Guard?  Yes      No

 

Please describe any special skills or training acquired while in the service: ___________________________________________________________________________________________________________

 

___________________________________________________________________________________________________________

 

What foreign languages do you speak, read, and/or write?

 

_________________________   Speak      Read       Write

 

_________________________   Speak      Read       Write

 

References:  Give name, address and telephone number of three references who are not related to you and have known you for 3 years or more.

____________________________________________________________________________________________________________

NAME                                                                                    ADDRESS                                                                                                      PHONE                                   RELATONSHIP TO YOU            TIME  KNOWN

 

____________________________________________________________________________________________________________

NAME                                                                                    ADDRESS                                                                                                      PHONE                                   RELATONSHIP TO YOU            TIME  KNOWN

 

____________________________________________________________________________________________________________

NAME                                                                                    ADDRESS                                                                                                      PHONE                                   RELATONSHIP TO YOU            TIME  KNOWN

 

 

EDUCATION

 

HIGH SCHOOL

 

______________________________________________________________________________________________________________________________________________________________________

NAME                                                                                                            ADDRESS                                                                                                      LAST YEAR COMPLETED                    RECEIVED DIPLOMA?

 

COLLEGE

 

______________________________________________________________________________________________________________________________________________________________________

NAME                                                                                                            ADDRESS                                                                                                      LAST YEAR COMPLETED                    RECEIVED DEGREE?

 

GRADUATE/PROFESSIONAL

 

______________________________________________________________________________________________________________________________________________________________________

NAME                                                                                                            ADDRESS                                                                                                      LAST YEAR COMPLETED                    RECEIVED DEGREE?

 

Describe specialized training, apprenticeship, and skills you possess not indicated above:

 

____________________________________________________________________________________________________________

 

 

___________________________________________________________________________________________________________

 

 

 

 

 

 

 

 

EMPLOYMENT EXPERIENCE

 

Start with your present or last position held. Include military service assignments and any verified work performed on a volunteer basis. Exclude organization names that indicate race, color, religion, sex, or national origin. Attach additional paper, if necessary.

 

NOTE:If you have a resume that provides the following information, please attach your resume and print “SEE RESUME” on the first employer’s line.

 

Employer

 

Work Performed

Address

 

 

Job Title

 

 

Supervisor

 

 

Dates Employed

 

 

Reason for

Leaving

 

 

 

Employer

 

Work Performed

Address

 

 

Job Title

 

 

Supervisor

 

 

Dates Employed

 

 

Reason for

Leaving

 

 

 

Employer

 

Work Performed

Address

 

 

Job Title

 

 

Supervisor

 

 

Dates Employed

 

 

Reason for

Leaving

 

 

 

Use additional paper for employment history, if necessary, or attach your resume.

 

It is my understanding that this employment application, or the granting of an interview, does not represent a contract of employment or a promise of future benefits by the Town of Dudley. I understand and agree that if hired, my employment will be at-will in nature and may be terminated, with or without cause, at any time, by either my employer or myself. I also understand that this written statement supersedes any and all verbal representations made by agents or representatives of the Town of Dudley.

 

AGREEMENT:  I certify that the information on this application is true, complete and accurate. I authorize the Town of Dudley to investigate my past employment, education and activities and I release from all liability all persons, companies and corporations supplying such information. I understand that false answers, statements or significant omissions made by me on this form shall be sufficient cause for denial of employment or discharge. Offer of employment is contingent on passing a physical examination that applies to the essential functions of the job.

 

________________________________________________________________________________________________________

                        Signature of Applicant                                                                                                                                                                                                                                   Date