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

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}