EMPLOYMENT APPLICATION

NEW ENGLAND PEDIATRIC CARE

NEW ENGLAND PEDIATRIC CARE

Step 1 of 3

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This Facility is committed to a policy of nondiscrimination and equal opportunity for all employees and qualified applicants without regard to race, religious creed, national origin, ancestry, gender, age, handicapped condition, veteran status, sexual orientation or physical/mental disability (provided the disability does not impair the ability to perform the essential duties of the job).

Please complete this application accurately and thoroughly. No question on this application is asked for the purpose of unlawfully limiting or excluding any applicant from consideration for employment due to race, color, religion, national origin, ancestry, marital status, gender, age, handicap, veteran status, sexual orientation, or with respect to physical or mental disability.

Your application for employment will remain in our file for one year. During this time period your employment history and skills will be reviewed and evaluated by our staff. Your application is our main source of information concerning your qualifications. It is not possible to interview all applicants and therefore, we ask that you be as specific as possible when completing this application. Please feel free to add information you consider useful in our selection of the most qualified applicant

Personal Information

First Name

Last Name

Email*(Required)

Home Phone

Cell phone

Street and Number

City

State

Zip Code

Are you under 18 years of age?

Yes

If under 18, Date of birth

MM slash DD slash YYYY

Are you vaccinated against COVID-19?

Yes

If so, have you received a booster?

Yes

Note: If under 18 years of age, you will need to provide an employment permit if employment is offered to you.

Are you legally entitled to work in the U.S.?

Yes

Hidden

Emergency contact:

Emergency contact

Address

Phone: Cell

Home

Have you previously been employed by this facility?

Yes

If yes give dates

MM slash DD slash YYYY

Position held

List any relatives who are currently employed by this facility:

Have you previously served as a volunteer?

Yes

Hospital/Agency

Dates

MM slash DD slash YYYY

Area of Service

Position or Type of Work Desired:(Required)

Preferred Shift

Day (6:45am - 3:15pm)

Evening (2:45pm - 11:15pm)

Night (10:45pm - 7:15am)

Week End

Other

Seeking

Full time

Part time

Regular

Temporary

Days Available

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Date available to begin working, if accepted

MM slash DD slash YYYY

The facility accommodates the religious practices of its employees whenever practicable

Educational Information

High School

Name

City

Years attended

Date Graduated

MM slash DD slash YYYY

If GED, date rec’d

MM slash DD slash YYYY

College Attended

Location

Attended (Yr to Yr)

Did you Graduate?

Diploma or Degree

Did you Graduate?

Yes

Course of Study

Major

Minor

Other College Attended

Location

Attended (Yr to Yr)

Did you Graduate?

Diploma or Degree

Did you Graduate?

Yes

Course of Study

Major

Minor

Employment History

(List current or most recent employer first. You may include any verified work Personal Information performed on a volunteer basis.)

Name and Address of Last Employer

Name

Address

City

Phone

Title of position held

Duties and responsibilities

Dates of Last Employment

From (month/year)

MM slash DD slash YYYY

To (month/year)

MM slash DD slash YYYY

Last Salary

Reason for Leaving

Immediate Last Supervisors Information

Name

Phone

May we contact this employer?

Yes

Status:

F.T

P.T

Relief

Name and Address of Second Last Employer

Name

Address

City

Phone

Title of position held

Duties and responsibilities

Dates of Second Last employment

From (month/year)

MM slash DD slash YYYY

To (month/year)

MM slash DD slash YYYY

Last Salary

Reason for Leaving

Immediate Second Last Supervisors Information

Name

Phone

May we contact this employer?

Yes

Status:

F.T

P.T

Relief

Name and Address of Third Last Employer

Name

Address

City

Phone

Title of position held

Duties and responsibilities

Dates of Third Last employment

From (month/year)

MM slash DD slash YYYY

To (month/year)

MM slash DD slash YYYY

Last Salary

Reason for Leaving

Immediate Third Last Supervisors Information

Name

Phone

May we contact this employer?

Yes

Status:

F.T

P.T

Relief

Professional Licenses, Certifications and/or Registration

Date first employed in Massachusetts:

Type

State issued

Date Issued

Expires

Number

Type

State issued

Date Issued

Expires

Number

Type

State issued

Date Issued

Expires

Number

Professional Activities:

List membership in any professional associations (indicate the extent of your participation including any offices which you held.)

U.S. Military Service

Branch of Service

Date Entered

MM slash DD slash YYYY

Date Separated

MM slash DD slash YYYY

Type of Discharge

Nature of duties and special training received

Certification

AFTER COMPLETING APPLICATION, PLEASE READ CAREFULLY AND SIGN

I give permission to the facility to investigate all pertinent information concerning my application in order to determine my qualifications for employment. I understand that falsification, misrepresentation or omission of facts called for in this application may result in denial of employment or immediate dismissal.
I understand that any offer of employment made to me is conditioned based on satisfactory results of a physical examination given by medical personnel approved by the facility and to undergo such an examination in the event I am offered employment.
I agree that any personal property carried by me from the facility premises, including packages, briefcase or other hand carried items may be inspected by authorized personnel.
In the event of my employment, I agree to comply with all facility rules and regulations as they may be changed from time to time. I understand that neither this employment application, nor any other facility document constitutes personal contract of employment. I further understand that my employment is for no stated term and may be terminated at the will of the facility. In the event that I decide to leave the facility, I agree to give proper notice of resignation and I understand that if I fail to do so, I will not be entitled to certain benefits which I would otherwise receive.
In the event of resignation or termination. I agree to return all property loaned to me such as badges, uniforms, library books, keys, etc.. If these items are not returned, the facility may withhold from any final compensation due me, monies to cover the value of any unreturned health systems property.
I understand that any offer of employment is conditioned on my submission of satisfactory proof of my legal eligibility to work in the United States

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.

I have read, understood and consented to the above statements. This authorization or photocopy shall serve as a consent for the facility to request any information concerning my application.