Online HHCC Job Application
Personal Information
Name
First Name
Last Name
Initials
SSN
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Email Address
example@example.com
Education History
Name and Location
Years Attended
Did You Graduate?
Subjects Studied
High School
Other
Special Training/Certification
HHA
PC
Supportive
Homemaker
Clerical
Availability
Please indicate the days and hours you are available to work. Schedules cannot be changed once hired for the first six months, and then only if approved by the department Supervisor and the Executive Director.
Days
Mon
Tues
Wed
Thurs
Fri
Sat
Sun
Hours
Evenings
Mon
Tues
Wed
Thurs
Fri
Sat
Sun
Hours
Former Employers
List most recent employer first
Business Name
Address
Phone Number
Please enter a valid phone number.
From
-
Month
-
Day
Year
Date
To
-
Month
-
Day
Year
Date
Your Position
Salary
Reason For Leaving
Business Name
Address
Phone Number
Please enter a valid phone number.
From
-
Month
-
Day
Year
Date
To
-
Month
-
Day
Year
Date
Your Position
Salary
Reason for Leaving
Professional References (List the names of at least three persons who know you professionally)
Reference Name
Business Name
Address
Phone
Years Known
Relationship (supervisor, co-worker, etc)
1
2
3
4
Authorization
“I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information. I authorize HHCC to conduct and Identity, criminal and driving background checks in Commonwealth of Massachusetts and in any countries, states, and countries in which I may resided during the past 20 years. I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative. This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws.”
Signature
Date
-
Month
-
Day
Year
Date
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