Employment Application Form in Holyoke, MA | Mt. Tom Boarding and Grooming

To Applicant: We deeply appreciate your interest in our organization and assure you that we are sincerely interested in your qualifications. A clear understanding of your background and work history will aid us in placing you in the position that best meets your qualifications and may assist us in possible future upgrading.
Personal
Date
Name*
First Middle Initial Last
Social Security No:
Present Address:
Street Address City State Zip Country
Telephone No:*
If you have lived at your current address for less than five years, fill out previous address:
Previous Address:
Street Address City State Zip
How long did you live there?
To Applicant: READ THIS INTRODUCTION CAREFULLY BEFORE ANSWERING ANY QUESTIONS IN THIS BOXED-OFF AREA! The Civil Rights Act of 1964 prohibits discrimination in employment practices because of race, color, religion, sex or national origin. P.I. 90.282 prohibits discrimination on the basis of age with respect to individuals who are at least 40 but less than 65 years of age. The laws of some states also prohibit some or all of the above types of discrimination. DO NOT ANSWER ANY QUESTION IN THIS BOXED OFF AREA UNLESS THE EMPLOYER HAS CHECKED THE BOX NEXT TO THE QUESTION, thereby indicating that the requested information is needed for a bona fide occupational qualification, national security laws, or other legally permissible reasons.
Are you over the age of 21?*
- Yes
- No
If not, hire is subject to verification that you are of minimum legal age.
Sex
- Male
- Female
Height:
Weight:
Marital Status
- Single
- Engaged
- Married
- Separated
- Divorced
- Widowed
Date of Marriage if applicable:
No. of dependents including yourself
Are you a citizen of the U.S.A.?*
- Yes
- No
What is your present Selective Service classification?
Indicate dates you attended school:
High School from and to
College from and to
Other (specify type of school) from and to
Have you ever been bonded?
- Yes
- No
If yes, on what jobs?
Employer may list other bona fide occupational questions on lines below:
What method of transportation will you use to get to work?
Position(s) applied for:
Rate of pay expected: $ per hour
Would you work
Full-time
Part time
If part time, specify days and times:
Days Available
Times Available
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Were you previously employed by us?
If yes, when?
List any friends or relatives working for us:
If your application is considered favorably, on what date will you be available for work?
Are there any other experiences, skills, or qualifications which you feel would especially fit you for work with the company?
Do you have any physical defects which preclude you from performing certain kinds of work?
- Yes
- No
If yes, describe such defects and specific work limitations:
Have you been convicted of a crime in the past ten years, excluding misdemeanors and summary offenses?
- Yes
- No
If yes, describe in full:
Have you had a major illness in the past 5 years?
- Yes
- No
If yes, please describe:
Have you received compensation for injuries?
- Yes
- No
If yes, please describe:
Record of Education
- School
- Name & Address of School
- Course of Study
- Check Last Year Completed
- Did You Graduate?
- List Diploma or Degree
- High School
- - 1
  - 2
  - 3
  - 4
- - Yes
  - No
- College
- - 1
  - 2
  - 3
  - 4
- - Yes
  - No
- Other (Please specify)
- - 1
  - 2
  - 3
  - 4
- - Yes
  - No
Military Service Record
Were you in the U.S. Armed Forces?
- Yes
- No
Dates of Duty: From and to
Rank at discharge:
Have you taken any training under the G.I. Bill of Rights?
- Yes
- No
If yes, what training did you take?
3 Personal References
(NOT former employers or relatives)
Name
Occupation
Address
Telephone No.*
Previous Work Experience
- Name & Address of Company
- From-Month/Year
- Weekly Starting Salary
- To-Month/Year
- Describe in detail the work you did
- Weekly Ending Salary
- Reason for Leaving
- Name of Supervisor
- Name & Address of Company
- From-Month/Year
- Weekly Starting Salary
- To-Month/Year
- Describe in detail the work you did
- Weekly Ending Salary
- Reason for Leaving
- Name of Supervisor
- Name & Address of Company
- From-Month/Year
- Weekly Starting Salary
- To-Month/Year
- Describe in detail the work you did
- Weekly Ending Salary
- Reason for Leaving
- Name of Supervisor
- Name & Address of Company
- From-Month/Year
- Weekly Starting Salary
- To-Month/Year
- Describe in detail the work you did
- Weekly Ending Salary
- Reason for Leaving
- Name of Supervisor
May we contact the employers listed above?
If not, indicate which one(s) you do not wish us to contact:
The facts set forth above in my application for employment are true and complete. I understand that if employed, false statements on this application shall be considered sufficient cause for dismissal. You are hereby authorized to make any investigation of my personal history and financial credit record through any investigative or credit agencies or bureaus of your choice.
Signature of Applicant
How many hours are you able to work?
What is the pay scale you require or would like to start with?
Do you have any commitments that require you to be out of work early any day of the week or on weekends during any time of the year?
Please list ANY questions you have that we may answer for you:
For Interviewers Use Only
Interviewer
Date
Comments
Reference Check
Reference No.
Results
Reference No.
Results

Personal

Record of Education

Military Service Record

3 Personal References

Previous Work Experience

For Interviewers Use Only

Reference Check