The Consortium Job Application

Application for Employment

Please complete the form below to apply for a position with us.
Applicants for employment are considered without regard to race, creed, color, religion, sex, sexual orientation, marital status, genetic information, national origin, age and disability, military or veteran status, Vietnam Era Veteran, or being a member of the Reserves or National Guard. 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.
Position Applying For:*
Date of Application: *

MonthDayYear
Date
Full Name:*

FirstMiddle Last
Current Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone Number*

Area CodePhone Number
Cell Phone Number*

Area CodePhone Number
Best way to reach you? (number and time of day)*
What is your email address:*
YESNO
If YES, work number and best time to call?*

Educational Background

List levels of education, including the number of years completed, indicated degree or diploma earned as applicable and major field of study. **Enter "N/A" if does not apply.

Rows	Name of School	Years Completed	Degree/Diploma	Major
High School
College University
**Trade/Other

***For Home & Community Connections Program only (per our funder):

Applicants will be required to produce documentation at their first interview proving their highest level of education attained (e.g. High School Diploma, G.E.D., Bachelor’s Degree, Master’s Degree, Licensed Certifications, etc.).
List Specialized Skills or Training (First Aid, CPR, Med. Cert., C.N.A., Speak/Write other language, etc.):*

Employment and Relevant History

List your last three (3) employers, volunteer, or relevant personal experience starting with the most recent, including military experience. (Completion of this section is required even when submitting a resume.)
Employer:Name of Employer* Telephone:    *
Address: Address*      City*   State*   Zip*
Immediate Supervisor and Title:   Full Name*   Title*
Reason for Leaving:   Reason*
May we contact for reference?    YES    NO
Dates employed: FROM:   Date*   TO:   Date*
Summarize job responsibilities: *
Employer:Name of Employer* Telephone:    *
Address: Address*      City*   State*   Zip*
Immediate Supervisor and Title:   Full Name*   Title*
Reason for Leaving:   Reason*
May we contact for reference?    YES    NO
Dates employed: FROM:   Date*   TO:   Date*
Summarize job responsibilities: *
Employer:Name of Employer* Telephone:    *
Address: Address*      City*   State*   Zip*
Immediate Supervisor and Title:   Full Name*   Title*
Reason for Leaving:   Reason*
May we contact for reference?    YES    NO
Dates employed: FROM:   Date*   TO:   Date*
Summarize job responsibilities: *
List Any Additional Professional References:
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
May we contact?*
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
May we contact?*
It is my understanding that this employment application, or the granting of an oral interview, does not represent a contract of employment or a promise of future benefits by this company/organization. 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 myself or my employer. I also understand that this written statement supersedes any and all oral representations made by agents or representatives of this company/organization.

AGREEMENT:

I certify that the information on this application is true, complete and correct. I hereby authorize the investigation of 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.
Printed Name*

First NameLast Name
Signature*

Clear
Date*

MonthDayYear
Date
Revised 01-14-2025
Should be Empty:

Rows	Daytime	Evening	Overnight
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

Application for Employment

Job Information

Educational Background

Employment and Relevant History