Name

First:

Middle:

Last:

Present Address

Street:

City:

State:

Zip:

Permanent Mailing Address

Street:

City:

State:

Zip:

Telephone

Day:

Evening:

Are you 18 years or older?:
Military Status:

How did you hear about this position?

By whom were you referred?

Name of Website(s):

Name of Newspaper:

Do you have friends or relatives working here?:
If yes, please gives names and positions:

Residency

Are you either a U.S. Citizen or an Alien authorized to work in the United States?:
If hired, you will be required to submit, as a condition of employment, proof of your identity and legal work authorization within 3 business days.

Employment Desired & Site Location

Position:

Location:

Date you can start:

Type of hours desired:
Have you ever applied to CCI before?:
If yes, dates:
Have you ever been employed by CCI before?:
If yes, dates:
Can you travel if required by your job?:

Education

High School

Name and Location of School:

# Years Attended*:

Did You Graduate?:
Subjects Studied:

College

Name and Location of School:

# Years Attended*:

Did You Graduate?:
Subjects Studied:

Graduate, Trade, Business, Night, Correspondence

Name and Location of School:

# Years Attended*:

Did You Graduate?:
Subjects Studied:
*Do not provide dates. State and Federal laws prohibit discrimination on the basis of age.

General

Academic Honors, Awards, Special Recognition or Extra Curricular Activities:
Subjects of Special Study or Research:
Summarize Special Working Skills:

Employment History

Please complete in full even if you have a resume. List the last three employers, starting with the last one first. You may include military service or any verified work performed on a volunteer basis.

Employer 1

Name/Address/Phone of Employer. Include Contact Person or Supervisor:
Dates Employed and Position:
Reason for Leaving:

Employer 2

Name/Address/Phone of Employer. Include Contact Person or Supervisor:
Dates Employed and Position:
Reason for Leaving:

Employer 3

Name/Address/Phone of Employer. Include Contact Person or Supervisor:
Dates Employed and Position:
Reason for Leaving:

References

Give the names of three references, preferably three professional. Personal references, not related to you, whom you have known for at least one year, are acceptable.

Reference 1

Name:

Address:

Phone:

Reference 2

Name:

Address:

Phone:

Reference 3

Name:

Address:

Phone:

Emergency Information

In case of emergency, please notify:

Contact 1

Name:

Address:

Phone:

Contact 2

Name:

Address:

Phone:

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 and civil liability.

Applicant's Statement

  1. I understand that the receipt of this application does not imply that I will be employed.
  2. I certify that the answers given in this application are true and complete to the best of my knowledge. I understand that false or misleading information given in my application or interview(s) may result in withdrawal of a job offer or discipline up to and including termination of employment, whenever the omission or falsehood is discovered.
  3. I further understand and acknowledge that, if hired, any employment relationship with this Company is of an “at-will” nature, which means that I may resign at any time and the Company may discharge my employment at any time with or without cause. It is further understood that this “at-will” employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by a corporate officer of the Company. No manager, supervisor or other individual at the Company has authority to make a commitment of guaranteed or continuing employment to me, and no document or publication, including handbooks and policy manuals of the Company should be interpreted to make such a guarantee.
  4. I understand that Community Connections, Inc. will verify the statements and information contained in this Application. I agree to sign the proper authorization and release forms in regard to the Company’s verification and investigation of this information.
  5. I understand that if hired, I will be required to sign a Confidentiality Agreement as a condition of my employment with the Company.
My signature certifies that I have read and agree with the above statements.

Applicant Signature:

Date:

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Support Us and Our Efforts


Your donation counts in so many ways to the people served by Community Connections and to the staff that supports us every day. There are a variety of ways to donate to Community Connections, whether you are an individual, business or charitable foundation. Community Connections, Inc. is a nonprofit 501(c)(3) corporation and donations are tax-deductible.