Return to Work Form

Job Seeker Placement Form
► Congratulations on finding a job! Use this form to tell us a little information about where you're working, how you heard about it, and if you'd like to continue hearing from us. Again, way to go, you!
Job Seeker Information
Job Seeker Name*

First NameLast Name
Job Seeker ID
(Please No Dashes or Spaces)
Email Address*
example@example.com
Employer Information
Business Name*
Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer Phone
Please enter a valid phone number.Format: (000) 000-0000.
Industry
Job Title*
Start Date*

MonthDayYear
Date
Were you offered medical benefits at the time of hire (regardless if accepted or not)?*

YesNo
Were you offered a retirement plan at the time of hire (regardless if accepted or not)?*

YesNo
Hours per Week*
Pay Rate
Did you learn of this position from MassHire South Shore?*

Referred by StaffDirect Recruitment EventJob FairOther (Provide Details Below)No
Additional Relevant Details
Would you like to be unsubscribed from MassHire South Shore email marketing?

YesNo
Should be Empty:

Job Seeker Placement Form