Fillable Richard D. Carney Municipal Office Building 100 Maple (SELCO)

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Richard D. Carney Municipal Office Building 100 Maple (SELCO)

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1
Richard D. Carney Municipal Office Building
100 Maple Avenue
Shrewsbury, MA 01545
The Town of Shrewsbury is an Affirmative Action / Equal Employment
Opportunity Employer
All information must by typed or printed in readable writing. Unreadable application will be discarded.
1. Date of Application: 2. Position Applying For:
3. Name:
Last First Middle
4. Address:
Number Street Apartment Number
City/Town State Zip Code
5. Telephone Number: Primary:
Area Code / Number
6. Email Address: ______________________________________________________________________________________________
7. If hired, can you provide proof of citizenship or legal right to work? YES NO
8. Are you under 18 years of age? YES NO If yes, date of birth?
9. Have you ever been employed by the Town before? YES NO
If yes, when? In which department?
10. Do you have an immediate family member (i.e. spouse, mother, father, sibling, or child) working for the Town of Shrewsbury?
YES NO
If yes, Employee’s Name: Department:
11. How did you learn about the job for which you are applying? Walk-in Town Employee
Newspaper; title Professional Journal; title
Posted Town Bulletin the Internet
Personal Information
2
Name / Location
Course of Study
Years
Completed
Did you graduate?
Degree / Date
High School
YES NO
College
YES NO
Graduate School
YES NO
Business/Technical
YES NO
12. Do you possess the following skills? Please list in detail all that apply.
Specialized Training? YES NO Name of Training/Course:
Professional Licenses? YES NO Licenses:
Professional Memberships? YES NO Name of Organizations:
Computer Software? YES NO Name of Programs:
Office Equipment? YES NO Describe Equipment:
If more room is required, an additional sheet may be attached.
List present employer first. A resume or supplemental sheet may be included, however, this section must be completed.
13. Employer’s Name:
Address: Telephone Number:
Job title: Worked From: To:
Immediate Supervisor’s Name and Job Title:
May we contact this employer? YES NO
Describe the work you performed:
Reason(s) for leaving:
14. Employer’s Name:
Address: Telephone Number:
Job title: Worked From: To:
Immediate Supervisor’s Name and Job Title:
May we contact this employer? YES NO
Describe the work you performed:
Reason(s) for leaving:
Education
Employment History
3
15. Employer’s Name:
Address: Telephone Number:
Job title: Worked From: To:
Immediate Supervisor’s Name and Job Title:
May we contact this employer? YES NO
Describe the work you performed:
Reason(s) for leaving:
16. Employer’s Name:
Address: Telephone Number:
Job title: Worked From: To:
Immediate Supervisor’s Name and Job Title:
May we contact this employer? YES NO
Describe the work you performed:
Reason(s) for leaving:
If more room is required, an additional sheet may be attached.
Please provide professional and/or business references only. Note that references listed in this section will be contacted after notice is given to
applicant.
17. Reference #1
Name: Address:
Business Position: Telephone Home:
Work:
18. Reference #2
Name: Address:
Business Position: Telephone Home:
Work:
19. Reference #3
Name: Address:
Business Position: Telephone Home:
Work:
20. Reference #4
Name: Address:
Business Position: Telephone Home:
Work:
References
4
The information provided in this application for employment is true and complete to the best of my knowledge. In the event of employment, I
understand that false or misleading information given in my application or interview(s) may result in discharge.
I authorize investigation of all statements contained in this application and the release of any pertinent information regarding my education, past
employment history and background. I authorize the Town of Shrewsbury to obtain any information from schools, employers or individuals relating
to my activities. This information may include, but is not limited to: academics, achievement, performance, attendance, personal history and
discipline. Further, I hereby authorize all references, persons, schools, my current employer (if applicable) and previous employers and organizations
named in this application, unless otherwise stated, to provide the Town of Shrewsbury any relevant information that may be required to arrive at an
employment decision. I understand that the information released is for the Town of Shrewsbury’s use only.
I hereby voluntarily release, discharge and exonerate the Town of Shrewsbury, its agents and representatives, and any person so furnishing
information from any and all liabilities of every nature and kind arising out of the furnishing or inspection of such documents, records and other
information or the investigations made by or on behalf of the Town of Shrewsbury.
I understand that all appointments are probationary and that I must demonstrate my ability for continued employment. I also understand that I must
be available from time to time to work outside normal business hours, as the needs of the department require.
If required for the position I am seeking, I agree to take a physical examination, which may include testing for drugs or a psychological examination,
as required, and recognize that any offer of employment may be contingent upon the results of such an examination.
I understand that any employment offer by the Town is conditional upon my ability to establish employment eligibility under the Immigration
Reform and Control Act of 1986 within three days of the date of hire.
I represent that I have read and fully understand the foregoing and seek employment under these conditions.
Signature: Date:
“Discrimination against any person in any practice or procedure in advertising, recruitment, referrals, testing, hiring,
transfer, promotion or any other term, condition or privilege of employment which limits or adversely affects employment
opportunities, because of political or religious opinions or affiliations, or because of race, color, sex, sexual orientation,
national origin, marital status, pregnancy, parenthood, age or handicap which is unrelated to the person’s occupational
qualifications or any other non-merit factor which is not a bona fide occupational qualification is prohibited.”
It is unlawful in Massachusetts to require a lie detector test as a condition of employment or continued employment. An
employer who violates that law shall be subject to criminal penalties and civil liabilities.
Agreement
5
I a candidate for the position of hereby authorize the
Town of Shrewsbury to investigate all statements in my application and to secure any necessary information from all my
employers, references, and academic institutions. I hereby release all of those employers, references, academic
institutions, and the Town of Shrewsbury from any and all liability arising from their giving or receiving information
about my employment history, my academic credentials or qualifications, and my suitability for employment with the
Town of Shrewsbury.
I
understand that any offer of employment is contingent upon receipt of a satisfactory report concerning my academic
credentials and employment references. I further understand that any false or misleading statements will be sufficient
cause for rejection of my application if the Town of Shrewsbury has not yet employed me and for immediate dismissal if
the Town of Shrewsbury has employed me. I also authorize the Town to supply information about my employment
record, in whole or in part, in confidence to any prospective employer, government agency, or other party having legal
and proper interest, and I hereby release the Town of Shrewsbury from any and all liability for its providing this
information.
In the event of my employment with the Town of Shrewsbury, I will comply with all rules, regulations, and policies set
forth in the Town of Shrewsbury’s Personnel Bylaw or other communications distributed by the Town of Shrewsbury.
I
understand that nothing in this employment application, in the Town of Shrewsbury’s policy statements or personnel
guidelines, or in my communications with any Town of Shrewsbury official is intended to create an employment contract
between the Town of Shrewsbury and me. No promises regarding employment have been made to me and I understand
that no such promise or guarantee is binding upon the Town of Shrewsbury unless it is made in writing and signed by an
authorized Town of Shrewsbury official.
I
hereby acknowledge that I have read and understand the preceding statement.
Signed: Date:
[Signature of Applicant]
TOWN OF
SHREWSBURY
RELEASE
The Town of Shrewsbury as part of its commitment to Affirmative Action / Equal Employment Opportunity
policies invites you to provide the following information. All applicants will be considered without regard to
race, color, religion, sex, gender identity, genetic information, sexual orientation, national origin, age, marital
status, veteran status, medical condition or disability, handicap of a qualified handicapped person unless based
upon a bona fide occupational qualification, or any other protected class under the law. The information is
voluntary and refusal to provide it will not have any bearing on our employment decision. The data is
confidential and will be filed separately. It will be available only to authorized personnel and is used to further
the Town’s Affirmative Action / Equal Employment Opportunity policies. Your cooperation is appreciated.
1. Position Title: ___________________________________
2. Gender: Male Female Non-Binary
3. Ethnic Origin:
White – All persons having origins in any of the original peoples of Europe, North Africa
or the Middle East.
Black – All persons having origins in any of the black racial groups of Africa.
Hispanic – All persons of Mexican, Puerto Rican, Cuban, Central or South American or
other Spanish culture or origin regardless of race.
Asian or Pacific Islander – All persons having origins in any of the peoples of the Far
East, Southeast Asia, the Indian Subcontinent, or the Pacific Islands. This area includes, for
example, China, Japan, Korea, the Philippine Islands and Samoa.
American Indian or Alaskan Native – All persons having origins in any of the original
people of North America maintaining cultural identification through tribal affiliations or
community recognition.
Cape Verdean – All persons having origins on the Cape Verde Islands.
4. National Origin: __________________________________
5. Veteran Status: Yes No
6. Vietnam Era, 1962-1975: Yes No
Voluntary Affirmative Action Request Form
7.
Disabled:
Yes
No
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Richard D. Carney Municipal Office Building 100 Maple (SELCO)

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Completed 5 August 2020

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