Fillable Printable Application for Employment - Commonwealth of Massachusetts
Fillable Printable Application for Employment - Commonwealth of Massachusetts
Application for Employment - Commonwealth of Massachusetts
Commonwealth of Massachusetts
EXECUTIVE BRANCH
Application for Employment
COMMONWEALTH OF MASSACHUSETTS
APPLICATION FOR EMPLOYMENT
2
IMPORTANT!
INSTRUCTIONS FOR COMPLETING THE APPLICATION FORM
Note: People using screen-reading software (e.g., JAWS) should navigate through this document using the arrow keys to avoid
updating unrestricted sections.
1. Type or print clearly in black or blue ink.
2. Answer every question fully and accurately. If not applicable, please put N/A.
3. For an applicant for employment who meets the minimum entrance requirements, the Commonwealth
may review later in the application process, if applicable:
• Criminal Offender Record Information (C.O.R.I) and;
• Sex Offender Registry Information (S.O.R.I.) and;
• The Central Registry of Child Abuse/Neglect reports maintained in accordance with M.G.L.
Chapter 119, Section 51 B.
4. If an offer of employment is made to you, the Commonwealth agency may declare that the offer is
contingent upon the successful results of a medical exam, references, education, certification,
professional licenses, driver’s license (if required for job) and/or a tax and background check.
5.
False or materially inaccurate information on the application will be cause for disqualification
for employment or dismissal at any time during employment.
6. Read certification and releases carefully before signing.
7. Return completed application.
8.
If there is a need for an alternative version of this form, please contact the Agency Diversity Office at
(508) 850-7730.
This application will be kept on file for 3 years but applicants are responsible for applying for each vacancy for
which there is an interest in being considered.
COMMONWEALTH OF MASSACHUSETTS
APPLICATION FOR EMPLOYMENT
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WE ARE AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER
It is the policy of the Commonwealth of Massachusetts to afford equal employment opportunity to all qualified persons regardless of
race, color, religious creed, national origin, age, military status, sexual orientation, disability, genetic information, gender identity,
gender expression or gender unless based upon a bona fide occupational qualification.
PERSONAL INFORMATION
First Name
Middle Initial
Last Name
Home Telephone Number
Personal Cell Phone Number
Email Address
Mailing Address
Street
City
State
Zip Code
Home Address - if different from mailing address
Street
City
State
Zip Code
Are you authorized to work in the U.S. on an unrestricted basis? YES NO
Are you 18 years or older? YES NO
Who referred you?
Current Employee
Employment Agency
Newspaper advertisement
Commonwealth’s Employment Opportunities (CEO)
Other Internet job site
Unemployment office/One-Stop Career Center
Other : _________________________________________________________________________________
EMPLOYMENT DESIRED
Position Applied For
How soon can you start if a job offer is made?
State Agency Applying
Have you worked for the Commonwealth before?
NO YES Dates:
Starting salary desired
Are you available for full time work? YES NO Are you available for part time work? YES NO
Have you reviewed the essential functions of the job as listed on the CEO or job posting? YES NO
In addition to your work history, what other experiences, skills or qualifications would qualify you for this work?
COMMONWEALTH OF MASSACHUSETTS
APPLICATION FOR EMPLOYMENT
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EDUCATION
N
ame of School
City
St
at
e
Main Course of Study
Did you
Graduate
Degree Years
Atten
ded
(Dates)
List any additional education or training
PROFESSIONAL REFERENCES
(not personal)
List 3 people not related to you who can comment on your work performance.
Name Address Occupation Telephone Number Years
Acquainted
MILITARY SERVICE INFORMATION
This information is furnished on a voluntary basis.
Check all that apply.
Not Indicated No Military Service Not a Veteran Active Reserve
Inactive Reserve Afghanistan Veteran Desert Shield Veteran Desert Storm Veteran
Disabled Veteran Iraq Veteran Operation Enduring
Freedom Veteran
Operation Iraq Freedom
Veteran
Other Protected Veteran Retired Military Vietnam Veteran Vietnam Era Veteran*
Recently Separated Veteran Armed Forces Services
Medal Veteran
Special Disabled Veteran
Dates of Most Recent Service: Branch?
If Vietnam Era Veteran, have you been certified by the Office of Diversity and Equal Opportunity? YES NO
If yes, what is the Certification Number?
*In order to qualify for Affirmative Action status as a Vietnam Era Veteran, you must apply for Eligibility Certification, which is issued by the Office
of Diversity and Equal Opportunity. Forms are available from the Office of Diversity and Equal Opportunity (617) 727-7441.
COMMONWEALTH OF MASSACHUSETTS
APPLICATION FOR EMPLOYMENT
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IMMEDIATE FAMILY WORKING IN MASSACHUSETTS STATE GOVERNMENT
Per Chapter 93 of the Acts of 2011 and Executive Order 444, please disclose any immediate family members, including those related
to your immediate family by marriage, who are employed by the Commonwealth of Massachusetts. You are required to complete the
information below. ”immediate family” is defined as a spouse, parent, child or sibling or the spouse of the candidate’s parent, child or
sibling. Include those employed in all branches of state government: judicial, legislative, executive, higher education and state
authorities; and those employed as regular or contract employees, or elected officials. This "sunshine disclosure" is intended to ensure
that the citizens of our Commonwealth have full confidence in their government and its hiring process. The disclosure will not be
used to exclude any qualified applicant seeking a position within the Executive Branch from receiving full consideration based on the
merits of his/her credentials and the requirements of the job.
IMMEDIATE FAMILY WORKING IN MASSACHUSETTS STATE GOVERNMENT
Name of Relative Relationship Title of Relative’s Job State Agency
COMMONWEALTH OF MASSACHUSETTS
APPLICATION FOR EMPLOYMENT
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COMPLETE ALL INFORMATION IN FULL. All applicants must complete this page(s) even if they are also submitting a resume.
BEGIN WITH YOUR MOST RECENT EMPLOYMENT, INCLUDING ANY PRESENT EMPLOYMENT. YOUR PRESENT
EMPLOYER WILL NOT BE CONTACTED WITHOUT YOUR PERMISSION. YOU MAY INCLUDE ANY VERIFIABLE
WORK PERFORMED ON A VOLUNTEER BASIS. ANY GAPS IN EMPLOYMENT MUST BE BRIEFLY EXPLAINED.
EMPLOYMENT HISTORY
Are you employed now? Yes No
Company Name Telephone May we contact? Yes No
Street Address
City
State
Zip Code
Job Title Supervisor
Specific Duties
Dates Employed From: To: Salary
Reason for Leaving
Company Name Telephone May we contact? Yes No
Street Address
City
State
Zip Code
Job Title Supervisor
Specific Duties
Dates Employed From: To: Salary
Reason for Leaving
Company Name Telephone May we contact? Yes No
Street Address
City
State
Zip Code
Job Title Supervisor
Specific Duties
Dates Employed From: To: Salary
Reason for Leaving
Company Name Telephone May we contact? Yes No
Street Address
City
State
Zip Code
Job Title Supervisor
Specific Duties
Dates Employed From: To: Salary
Reason for Leaving
Use additional pages if necessary to include all employment.
COMMONWEALTH OF MASSACHUSETTS
APPLICATION FOR EMPLOYMENT
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ALL APPLICANTS MUST SIGN AND SUBMIT THIS PAGE
RELEASE AND CERTIFICATION
PLEASE READ BEFORE SIGNING
I understand that the foregoing will be verified in order to expedite my application for employment with the Commonwealth of
Massachusetts. I hereby authorize the Commonwealth to conduct a full investigation into my background.
I authorize the Commonwealth 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 the
Commonwealth of Massachusetts for the purpose of making its hiring decision.
I agree that the Commonwealth 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.
I understand that unless I attain permanent status pursuant to MGL Chapter 31 or am subject to the terms of a collective
bargaining agreement and have completed the requisite probationary period, my employment will be at-will, which means
that both the Commonwealth of Massachusetts 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.
Signature of Applicant Date
Printed Name
“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.”
MGL Ch.149, Section 19B
COMMONWEALTH OF MASSACHUSETTS
APPLICATION FOR EMPLOYMENT
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Applicants with Special Language Skills or Professional Licenses or those applying to
agencies that are open nights and weekends should complete and submit this form.
MISCELLANEOUS JOB-RELATED INFORMATION
Shift preferred 1
st
(Days) 2
nd
(Evenings) 3
rd
(approx. 11:00pm –7:00am)
Are you available to work EVERY Saturday and Sunday? YES NO
Please prioritize your geographical preference(s) by numbering the boxes for locations to work.
1 means the most desired position; 6 equals the least desired location.
Boston Metro Boston Central Northeast Southeastern Western
CERTIFICATIONS AND LICENSES
List any professional licenses, registrations or certifications you possess.
License
License Number
Date Issued
State Issued
Expiration Date
License
License Number
Date Issued
State Issued
Expiration Date
License
License Number
Date Issued
State Issued
Expiration Date
License
License Number
Date Issued
State Issued
Expiration Date
ENGLISH LANGUAGE
Indicate your proficiency in the English Language below.
Simple Conversation
YES NO
Simple Reading
YES NO
Basic Writing
YES NO
List any language(s) other than English in which you are proficient, including Sign Language and Braille.*
LANGUAGE CAPABILITIES
Speaking Reading Writing
Language
HIGH
(Fluent)
MOD
(Good)
LOW
(Fair)
HIGH
(Fluent)
MOD
(Good)
LOW
(Fair)
HIGH
(Fluent)
MOD
(Good)
LOW
(Fair)
* If language proficiency is required, the Commonwealth may administer a Bilingual Certification Examination.
COMMONWEALTH OF MASSACHUSETTS
APPLICATION FOR EMPLOYMENT
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AFFIRMATIVE ACTION DATA RECORD
THIS IS A CONFIDENTIAL INSERT
APPLICANTS ARE ENCOURAGED BUT NOT REQUIRED TO COMPLETE
The Commonwealth of Massachusetts is committed in spirit as well as in action, to abide by all laws dealing with equal employment
opportunity. It is our policy to guarantee equal employment opportunities for all qualified persons without regard to their age, race,
religious creed, color, national origin, ancestry, marital status, gender, gender identity or gender expression, military status, sexual
orientation, or disability, which can be reasonably accommodated.
Further, the Commonwealth will act in good faith, to affirmatively recruit and consider for promotion individuals in protected
categories. Age, race, religious creed, color, national origin, ancestry, marital status, gender, military status, sexual orientation, or
disability are not factors in employment, promotion, transfer, compensation, lay-off, disciplining and termination.
In order to effectively monitor the success of our recruitment and employment efforts, it is requested that you provide the following
information. This information will be forwarded to Monserrate Quiñones, Director, Office of Diversity & Equal Opportunity, P.O.
Box 946, Norfolk, MA 02056.
The completion of this Data Record is optional. If you choose to volunteer the requested information please note
that all Affirmative Action Data Records are kept in a confidential file and are not a part of your application for
employment or your personnel file. Your cooperation is voluntary. Inclusion or exclusion of any affirmative
action data will not jeopardize or adversely affect any employment decision.
First Name
Middle Initial
Last Name
Address
Street
City
State
Zip Code
Telephone Number
CHECK ONE Male Female
COMMONWEALTH OF MASSACHUSETTS
APPLICATION FOR EMPLOYMENT
10
AFFIRMATIVE ACTION DATA RECORD
THIS IS A CONFIDENTIAL INSERT
APPLICANTS ARE ENCOURAGED BUT NOT REQUIRED TO COMPLETE
The Commonwealth of Massachusetts is committed in spirit, as well as in action, to abide by all laws dealing with equal employment opportunity. It
is our policy to guarantee equal employment opportunities for all qualified persons without regard to their age, race, religious creed, color, national
origin, ancestry, marital status, gender, gender identity or gender expression, genetic information, military status, sexual orientation, or disability,
which can be reasonably accommodated, unless there exists a bona fide occupational qualification.
Further, the Commonwealth will act in good faith, to affirmatively recruit and consider for promotion individuals in protected categories. Age, race,
religious creed, color, national origin, ancestry, marital status, gender, military status, sexual orientation, or disability are not factors in employment,
promotion, transfer, compensation, lay-off, disciplining and termination, unless there exists a bona fide occupational qualification.
In order to effectively monitor the success of our recruitment and employment efforts, it is requested that you provide the following information. This
information will be forwarded to Monserrate Quiñones, Director, Office of Diversity & Equal Opportunity, P.O. Box 946, Norfolk, MA 02056.
The completion of this Data Record is optional. If you choose to volunteer the requested information please note that all Affirmative Action
Data Records are kept in a confidential file and are not a part of your application for employment or your personnel file. Your cooperation
is voluntary. Inclusion or exclusion of any affirmative action data will not jeopardize or adversely affect any employment decision.
Are you Hispanic or Latino?
Yes No
A person of Cuban, Mexican, Puerto Rican, South or Central American, or other
Spanish culture or origin, regardless of race.
What is your race? Select one or more.
American Indian* or Alaska Native
*Requires supporting documentation of
Tribal affiliation or heritage)
A person having origins in any of the original peoples of North and South
America (including Central America) who maintains cultural identification
through tribal affiliation or community attachment.
Asian
A person having origins in any of the original peoples of the Far East, Southeast
Asia, or the Indian Subcontinent, including, for example, Cambodia, China,
India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and
Vietnam.
Black or African American A person having origins in any of the black racial groups of Africa.
Native Hawaiian or Pacific Islander
A person having origins in any of the original peoples of Hawaii, Guam, Samoa,
or other Pacific Islands.
White
A person having origins in any of the original peoples of Europe, the Middle
East, or North Africa.
Do you have a primary Ethnic Group (Optional)?
Hispanic or Latino American Indian or Alaska Native Asian
Black or African American Native Hawaiian or Pacific Islander White
No Primary
Applicant Signature, Name and Address
Date
COMMONWEALTH OF MASSACHUSETTS
APPLICATION FOR EMPLOYMENT
11
AFFIRMATIVE ACTION DATA RECORD
THIS IS A CONFIDENTIAL INSERT
APPLICANTS ARE ENCOURAGED BUT NOT REQUIRED TO COMPLETE
The Commonwealth of Massachusetts is committed in spirit, as well as in action, to abide by all laws dealing with equal employment
opportunity. It is our policy to guarantee equal employment opportunities for all qualified persons without regard to their disability
which can be reasonably accommodated.
Further, the Commonwealth will act in good faith, to affirmatively recruit and consider for promotion individuals in protected
categories. Disability is not a factor in employment, promotion, transfer, compensation, lay-off, disciplining and termination, unless
there exists a bona fide occupational qualification.
In order to effectively monitor the success of our recruitment and employment efforts, it is requested that you provide the following
information. This information will be forwarded to Monserrate Quiñones, Director, Office of Diversity & Equal Opportunity, P.O.
Box 946, Norfolk, MA 02056.
The completion of this Data Record is optional. If you choose to volunteer the requested information please note that all Affirmative
Action Data Records are kept in a confidential file and are not a part of your application for employment or your personnel file. Your
cooperation is voluntary. Inclusion or exclusion of any affirmative action data will not jeopardize or adversely affect any employment
decision.
First Name
Middle Initial
Last Name
Telephone Number
Check if the following is applicable:
Person with a disability*
A disability means a physical or mental impairment that substantially limits one or more major life activities; a record of such
impairment; or being regarded as having such an impairment. (“Major Life Activities” includes but is not limited to functions such as
caring for one’s self, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning and working). Information on
disability is maintained by the ADA Coordinator, Monserrate Quiñones, Director, Office of Diversity & Equal Opportunity, P.O. Box
946, Norfolk, MA 02056.
*If you wish to obtain Affirmative Action status as a Person with a Disability after you have been employed by this agency you may
need to submit self-identification and verification of such with the ADA Coordinator if your disability is not obvious. Appropriate
forms are available at this agency’s Diversity Office.
Signature of Applicant Date
Printed Name
