Kolburne School

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THE KOLBURNE SCHOOL, INC.
343 NM-Southfield Road, New Marlborough, MA 01230
(413) 229-8787

Application for Employment

TO APPLICANT: We deeply appreciate your interest in our organization. Thank you for taking the time to complete this application.

This is to notify all persons that The Kolburne School, Inc. does not discriminate against any person because of his/her race, color, citizenship status, religious creed, national origin, sex, sexual orientation, which shall not include persons whose sexual orientation involves minor children as the sex object, age, ancestry, physical or mental disability, marital status, status as a disabled or Vietnam Era veteran of the United States Armed Forces, or being a member of the Reserves or National Guard, or status in any group protected by state or local law, in the provision of or access to services, employment and activity. This is in accordance with all applicable federal and state law, including, but not limited to, Section 504 of the Rehabilitation Acts of 1973, as amended, the Americans with Disabilities Act, as amended, the Civil Rights Act of 1964, as amended., Article 114 of the Massachusetts Constitution, Chapters 151B and 272, sections 92,98, and 98A, of the Massachusetts General Laws and Executive Orders 227, 246 and 253.

This policy governs all aspects of employment, including, but not limited to, recruiting, selection, job assignments, promotion, termination, layoff, recall, transfer, leaves of absence, supervision, compensation, discipline, termination and access to benefits and training.

First Name
Last Name
Email
Phone
Mailing Address 1
Mailing Address 2
City
State
Zip Code
Social Security #
Date

Are you legally eligible for employment in the U.S.A.? yes no
If hired , you are required to submit proof of your eligibility for work in the U.S.A.

Are you over the age of eighteen? yes no
If no, hire is subject to verification that you are of minimum legal age.

Position(s) applied for

Were you previously employed by us? yes no
If yes, when?

If your application is considered favorably,
on what date will you be available for work?

Are there any job related experiences, skills, or qualifications which will be of special benefit in the job for which you are applying?

Referred by

TO THE APPLICANT: The Massachusetts Executive Office of Health and Human Services ("EOHHS") together with other Massachusetts agencies, laws and regulations, require that certain applicants and current employees submit to a background check including a Criminal Offender Record Information check (CORI). Kolburne School shall conduct the check and obtain/review such information, including information from the Criminal History Systems Board, only after the applicant has been deemed otherwise qualified for the position, has been selected as the final candidate and has been given a conditional offer of employment subject to consideration of any criminal record. For further information regarding the CORI process, please see the form "Information for Job Applicants - Criminal Offender Record Information", a copy of which is provided with this Application.

EMPLOYMENT HISTORY
List below present and past employment, beginning with your most recent
(you may include verifiable volunteer positions if you wish)

1
Company Name		Address
Type of Business		Phone
Dates of employment:
from		to
Weekly Starting Salary		Weekly Ending Salary
Reason for Leaving		Name of Supervisor
Describe the work you did:

2
Company Name		Address
Type of Business		Phone
Dates of employment:
from		to
Weekly Starting Salary		Weekly Ending Salary
Reason for Leaving		Name of Supervisor
Describe the work you did:

3
Company Name		Address
Type of Business		Phone
Dates of employment:
from		to
Weekly Starting Salary		Weekly Ending Salary
Reason for Leaving		Name of Supervisor
Describe the work you did:

4
Company Name		Address
Type of Business		Phone
Dates of employment:
from		to
Weekly Starting Salary		Weekly Ending Salary
Reason for Leaving		Name of Supervisor
Describe the work you did:

I hereby give permission to contact the employers listed above concerning my prior work experience as indicated below:

Employer 1? yes no
Employer 2? yes no
Employer 3? yes no
Employer 4? yes no

School	Name and Address of School	Course of Study	Last year completed	Did you Graduate?	List Diploma or Degree
Elem				yes no
High				yes no
College				yes no
Other (specify)				yes no

PERSONAL REFERENCES
(Not Former Employers or Relatives)

Name and Occupation	Address	Phone Number

May we telephone you to follow up on this application at home? yes no

If yes, what is the best time to call?

May we telephone you to follow up on this application at work? yes no

If yes, what is the best time to call?

What is your business telephone number?

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