NEW HIRE APPLICATION

CPS – CORRECTIONAL HEALTHCARE APPLICATION FOR EMPLOYMENT
NAME [LAST NAME FIRST]
SOCIAL SECURITY NO.
DATE OF BIRTH

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
PRESENT ADDRESS
APT NO.
CITY
STATE
ZIP
PERMANENT ADDRESS
APT NO.
CITY
STATE
ZIP
PREVIOUS ADDRESS
APT NO.
CITY
STATE
ZIP
PHONE#
Format: (000) 000-0000.
CELL PHONE#
Format: (000) 000-0000.
ARE YOU 18 YEARS OR OLDER?
ARE YOU LEGALLY AUTHORIZED TO WORK IN THE US?
EMAIL ADDRESS
example@example.com
DRIVER’S LICENSE ID NUMBER
DRIVER’S LICENSE EXPIRATION DATE

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
EMERGENCY CONTACT NAME
EMERGENCY CONTACT NAME
EMERGENCY CONTACT PHONE #:
Format: (000) 000-0000.
DESIRED EMPLOYMENT
POSITION
DATE YOU CAN START

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
SALARY DESIRED
ARE YOU EMPLOYED NOW?
IF SO MAY WE CONTACT YOUR EMPLOYER?
EVER APPLIED TO THIS COMPANY BEFORE?
WHERE?
WHEN?
REASON FOR LEAVING
NAME OF LAST SUPERVISOR AT THIS COMPANY
HOW DID YOU FIND OUT ABOUT THIS POSITION?

Other
EDUCATION

SCHOOL LEVEL

Rows	NAME AND LOCATION OF SCHOOL	NO. OF YEARS ATTENDED	DID YOU GRADUATE?	SUBJECTS STUDIED
HIGH SCHOOL
COLLEGE
TRADE, BUSINESS OR CORRESPONDENCE SCHOOL

GENERAL
SPECIAL TRAINING, CERTIFICATIONS, LICENSES
SPECIAL SKILLS, FOREIGHN LANGUAGES, ETC
FORMER EMPLOYERS
LIST BELOW LAST THREE EMPLOYERS, STARTING WITH THE MOST RECENT.
NAME OF PRESENT OR LAST EMPLOYER
Address

ADDRESS

Street Address Line 2

CITYSTATE

ZIP
STARTING DATE

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
LEAVING DATE

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
JOB TITLE
WEEKLY STARTING SALARY
WEEKLY FINAL SALARY
MAY WE CONTACT YOUR SUPERVISOR? YES NO
NAME OF SUPERVISOR
TITLE
PHONE
Format: (000) 000-0000.
DESCRIPTION OF WORK
REASON FOR LEAVING
NAME OF PREVIOUS EMPLOYER
Address

ADDRESS

Street Address Line 2

CITYSTATE

ZIP
STARTING DATE

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
LEAVING DATE

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
JOB TITLE
WEEKLY STARTING SALARY
WEEKLY FINAL SALARY
MAY WE CONTACT YOUR SUPERVISOR? YES NO
NAME OF SUPERVISOR
TITLE
PHONE
Format: (000) 000-0000.
DESCRIPTION OF WORK
REASON FOR LEAVING
NAME OF PREVIOUS EMPLOYER
Address

ADDRESS

Street Address Line 2

CITYSTATE

ZIP
STARTING DATE

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
LEAVING DATE

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
JOB TITLE
WEEKLY STARTING SALARY
WEEKLY FINAL SALARY
MAY WE CONTACT YOUR SUPERVISOR? YES NO
NAME OF SUPERVISOR
TITLE
PHONE
Format: (000) 000-0000.
DESCRIPTION OF WORK
REASON FOR LEAVING
REFERENCES

LIST PROFESSIONAL REFERENCES WHOM WE MAY CONTACT

Rows	NAME	ADDRESS	BUSINESS	PHONE #
-
-
-
-

SERVICE RECORD
HAVE YOU EVER SERVED IN THE U.S. ARMED FORCES?
BRANCH OF SERVICE
DISCHARGE DATE

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
RANK
HAVE YOU EVER BEEN CONVICTED OF, PLEAD GUILTY/NO CONTEST TO, OR HAD A SUSPENDED IMPOSITION OF SENTENCE FOR ANY OFFENSE OTHER THAN A MINOR TRAFFIC VIOLATION?
IF YES, EXPLAIN
[A CONVICTIONAL RECORD WILL NOT NECESSARILY EXCLUDE YOU FROM CONSIDERATION. THIS INFORMATION WILL BE USED ONLY FOR JOB-RELATED PURPOSES AND ONLY TO THE EXTENT PERMITTED BY LAW.]
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 STASTEMENTS 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 CONCERNINING 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 UTILLIZATION OF SUCH INFORMATION.

“I ALSO UNDERSTAND AND AGREE THAT NO REPRESENTATIVE OF THE COMPANY HAS ANY AUTHORITY TO ENTERE INTO ANY AGREEMENT FOR EMPLOYMENT FOR ANY SPECIFIED PERIOD OF TIME, 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 MEDCICAL INFORMATION IN A MANNER PROHIBITED BY THE AMERICANS WITH DISABILITIES ACT [ADA] AND OTHER RELEVANT FEDERAL AND STATE LAWS.”
DATE

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
SIGNATURE
RELEASE AND CERTIFICATION, ALL APPLICANTS MUST SIGN AND SUBMIT THIS PAGE
I understand that the foregoing will be verified in order to expedite my application for employment with the Correctional Psychiatric Services (I hereby authorize CPS to conduct a full investigation into my background).

I authorize CPS to obtain my previous work records, employment records, education, certification, professional licenses, driver's license and history (if job related), professional references and any other information concerning knowledge, skills, and abilities and all other necessary information. Further I grant authority to the keeper of these records to release said records to CPS for the purpose of making its hiring decision.

I agree that CPS shall not be liable in any respect if a job offer is not extended, is withdrawn, or my employment is terminated because of false statements, omissions or answers made by me on this application. I agree that my previous employers shall not be liable with regard to any information provided by them in connection with this release.

I certify under the pains and penalties of perjury that all statements made by me on this application are true and complete to the best of my knowledge and that I have withheld nothing, which, if disclosed, would affect this application unfavorably. I understand that any false statements, omissions or answers made by me on this application can result in my immediate termination.

In compliance with the Immigration and Reform and Control Act of 1986, I understand that after I accept the job offer and no later than my first day of work, I must complete and sign I-9 form, Section 1 Employee Information and Attestation. I understand that I will be required to provide approved documentation that verifies my right to work in the United States within 3 business days of my first day of employment. I have received the list of approved documents with this application.

Through this application, CPS HR collects a range of highly personal information voluntarily provided by users. Unless otherwise required by law (including public records law), CPS HR will use this information solely for hiring, payroll, and other human resources purposes.

I understand that once I have completed the requisite probationary period, my employment will be at-will, which means that both CPS and I are free to terminate the employment relationship at any time for any non-statutorily prohibited reason or for no reason at all, with or without notice.
I hereby acknowledge that I have read in full and understand the above statements and conditions of employment.
I hereby acknowledge that I have read in full and understand the above statements and conditions of employment.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
PREA

Inquiries
In accordance with National Standards to Prevent, Detect and Respond to Prison Rape, 28 CFR §· 115.17, a correctional facility must make the following inquiries on this page of any applicant for employment in a position that may have contact with inmates and all contractors who may have contact with inmates. In accordance with 28 CFR § 115.17 (g), any material omission in answering the following questions or the provision of materially false information, shall be grounds for disqualification or for termination if discovered after hire.
1. Have you ever engaged in or been accused of engaging in sexual harassment in any prior
If yes, please provide full details. (Attach additional sheets if necessary)
2. Have you ever resigned, left or been terminated from any job following allegations that you engaged in any form of sexual misconduct?
If yes, please provide full details. (Attach additional sheets if necessary)
I understand that I have a continuing, affirmative duty to immediately report in writing to CPS any such misconduct during the time I am employed by CPS. I further understand that failure to do so may result in disciplinary action up to and including discharge.
Signature
Print Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Current or Prior Knowledge of Incarcerated Persons Disclosure Form
Before and during your employment with CPS, whenever a member of your immediate family or known relative is committed to a correctional facility you must promptly make the fact and relationships known to your Immediate Supervisor, in order that steps may be taken, if necessary, to spare you embarrassment. Your information will be held confidential to the necessary authorities. This includes incarceration in any and all state and county facilities and includes any out-of-state incarceration.
1) Do you have friends, neighbors, relatives, significant others or acquaintances that have been or are currently incarcerated in the Massachusetts Department of Correction, Massachusetts County Jail System or in any prison or jail in any other state or country?
Name of Person
Describe relationship
Is person incarcerated or released
Dates of incarceration and if applicable release date
Have you ever visited this person in a correctional facility? If yes name the facility
Purpose of visit
Is person incarcerated or released
When did you visit
How often do/did you visit
2) Have you ever been barred or denied access at any correctional/jail facility?
If yes facility and reason
3) Have you ever communicated with any inmate or former inmate via letter, computer, telephone or other form of communications?
If yes describe
Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
(Print)
Should be Empty:

CPS – CORRECTIONAL HEALTHCARE APPLICATION FOR EMPLOYMENT

DESIRED EMPLOYMENT

EDUCATION

GENERAL

FORMER EMPLOYERS

REFERENCES

SERVICE RECORD

AUTHORIZATION

RELEASE AND CERTIFICATION, ALL APPLICANTS MUST SIGN AND SUBMIT THIS PAGE

PREA

Current or Prior Knowledge of Incarcerated Persons Disclosure Form