174 Hampden Street
Boston, MA 02119
(617) 445-5900

APPLICATION FOR EMPLOYMENT

GENERAL INFORMATION
Please fill out completely or insert “N/A” (Not Applicable)
Name
LAST

FIRST

MIDDLE
List your addresses for the past 3 years
Current Address
STREET

CITY, STATE

ZIP

How Long? (months)
Previous Address
STREET

CITY, STATE

ZIP

How Long? (months)
Previous Address
STREET

CITY, STATE

ZIP

How Long? (months)
     
Home Phone: Cell Phone : Email :
Have you been employed at NEBS before? YES NO From : To :
Availability for work?(date) Part Time Full Time Temporary
If necessary, can you work evenings and/or weekends? YES NO
How did you find out about employment opportunities at NEBS? Newspaper Radio TV Web
Walk-in Sign/Banner Job Fair Referral If Referred, by whom?
Have you ever been convicted of a felony or a violent misdemeanor in the last 7 years? (A conviction will not necessarily bar applicant from employment; do not disclose convictions that have been sealed, expunged, annulled or dismissed)
YES NO If yes, please explain:
Can you produce documents to show you are legally eligible to work in the U.S.? (NOTE: any offer of employment is conditioned upon completing form I-9 and providing appropriate documentation) YES NO
Position(s) applying for : Minimum salary expected?
Are you able to perform the essential function(s) of the job(s) applied for either with or without an accommodation?
YES NO Describe :
Do you read, speak or write any languages besides English? Please List :
EDUCATION
School Name Address Degree or Diploma
High School
College
Vocational School
Graduate School
List any Certifications
Do you plan to further your education? YES NO If yes please explain:
Please list any special skills or areas of experience that relate to the position being applied for:
EMPLOYMENT HISTORY
Must be filled out completely, please list most recent employment first. Applicants for the position of driver must show all employment for the past three years and show commercial driving employment for a seven-year period preceding the three years. If more space is needed, you may attach an additional sheet.
Date Employed Employer
From To

MM/YY

MM/YY
Rate of Pay
Start Finish

$

$
Name
Street
City
State Zip :
Phone
Reason for leaving:
May we contact this employer: YES NO
Your Job Title:
Were you subject to the Federal Motor Carrier Safety
Regulations while employed?
YES NO
Was your job designated as a safety-sensitive function in
any DOT-related mode subject to the drug & alcohol
testing requirements o State Zip f 49 CFR Part 40?
YES NO
Major Duties:
Supervisor
Date Employed Employer
From To

MM/YY

MM/YY
Rate of Pay
Start Finish

$

$
Name
Street
City
State Zip :
Phone
Reason for leaving:
May we contact this employer: YES NO
Your Job Title:
Were you subject to the Federal Motor Carrier Safety
Regulations while employed?
YES NO
Was your job designated as a safety-sensitive function in
any DOT-related mode subject to the drug & alcohol
testing requirements o State Zip f 49 CFR Part 40?
YES NO
Major Duties:
Supervisor
Date Employed Employer
From To

MM/YY

MM/YY
Rate of Pay
Start Finish

$

$
Name
Street
City
State Zip :
Phone
Reason for leaving:
May we contact this employer: YES NO
Your Job Title:
Were you subject to the Federal Motor Carrier Safety
Regulations while employed?
YES NO
Was your job designated as a safety-sensitive function in
any DOT-related mode subject to the drug & alcohol
testing requirements o State Zip f 49 CFR Part 40?
YES NO
Major Duties:
Supervisor
Date Employed Employer
From To

MM/YY

MM/YY
Rate of Pay
Start Finish

$

$
Name
Street
City
State Zip :
Phone
Reason for leaving:
May we contact this employer: YES NO
Your Job Title:
Were you subject to the Federal Motor Carrier Safety
Regulations while employed?
YES NO
Was your job designated as a safety-sensitive function in
any DOT-related mode subject to the drug & alcohol
testing requirements o State Zip f 49 CFR Part 40?
YES NO
Major Duties:
Supervisor

Professional References
Name Occupation City, State Phone Number Relationship

CERTIFICATION AND AGREEMENT

This certifies that this application was completed by me and that all entries on it and information in it are true and complete to the best of my knowledge. I understand that falsification or incompleteness of this information may result in my not being considered for employment or dismissal if I am employed. I authorize the references, former employers and educational institutions listed on this application to give you any and all information concerning my previous employment and/or education achieved they may have, personal or otherwise, and release all parties from all liability for any damages that may result from furnishing any lawful job-related information. I understand that before any offer of employment is extended and/or before actual employment commences, I may be required to submit to a background check as required by the Company. I may also be required to submit to blood, urine, and/or other medical testing for detection of alcohol, drugs, and/or other controlled substances in accordance with Company policies post-offer. Additionally, I may be required by the Company to submit to a postoffer physical examination. Unsatisfactory or inconclusive results of the post-offer examination may necessitate withdrawal of the job offer.

If I am a candidate for a position involving the operation of a commercial motor vehicle, I hereby acknowledge that I have been made aware that the information I have provided with respect to my previous employers may be used, and my previous employers may be contacted, for the purpose of investigating my background as required by 49 CFR §391.23. I understand as a condition of employment, I will be required to show identification which proves my legal right to work in the United States. If employed, I agree to follow the rules, regulations and other directives of the Company. However, I understand that my employment is "at-will" and can be terminated, with or without cause, and with or without notice, at any time, at the option of either the Company or myself. I understand that no Company representative other than the Chief Executive Officer (CEO), has any authority to enter into any agreement to employ me for any specific period of time, or to make any agreement contrary to the foregoing. Any contrary agreement by the CEO must be in writing, signed and dated. I acknowledge that no other representatives have been made to me as of this date concerning employment by the Company. I have carefully read and understood the above, and hereby consent and agree to these conditions in exchange for the Company’s consideration of my application for employment.

49 CFR §391.23(d) and (e). I understand that I have the right to:

WE PARTICIPATE IN E-VERIFY

NOTICE: Federal law requires all employers to verify the identity and employment eligibility of all persons hired to work in the United States. This Security Work Authorization (SWA) will provide the Social Security Administration (SSA) and, if necessary, the Department of Homeland Security (DHS), with information from each applicant’s Form I-9 to confirm work authorization. IMPORTANT: If the Government cannot confirm that you are authorized to work, this SWA is required to provide you written instructions and an opportunity to contact SSA and/or DHS before taking adverse action against you, including terminating your employment SWA and employers may not use E-Verify to re-verify current employees and may not limit or influence the choice of documents presented for use on the Form I-9. If you believe that your SWA has violated its responsibilities under this program or has discriminated against you during the verification process based upon your national origin or citizenship status, please call the Office of Special Counsel for Immigration Related Unfair Employment Practices at 1-800-255-7688 (TDD: 1-800- 237-2515).


SIGNATURE OF APPLICANT

DATE