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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.

Date
 
Name
 
Address
 
City
 
State
 
Zip Code
 
Social Security #
 
Phone
 
Email
 

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 Executive Office of Health and Human Services/Office of Child Care Services requires all staff at Kolburne School to complete a Criminal Offender Record Information check (CORI). The Office of Child Care Services regulations indicate which felony(s) or misdemeanor(s) exclude staff from employment. Kolburne may request periodic CORI checks during the course of employment. A candidate/applicant is not required to disclose on a CORI application: a) any arrest, detention, or disposition if they were not convicted of a crime; b) a first conviction for the misdemeanors of drunkenness, simple assault, speeding, minor traffic violations, or disturbance of the peace; or 3) any conviction for a misdemeanor that occurred five years ago.
Have you ever been convicted of a crime?
YES NO, if YES, list convictions:


(A conviction does not necessarily disqualify an applicant from the position being offered)

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

 

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

 

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

 

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

I hereby give permission to contact the employers listed above concernong 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 home? yes no

If yes, what is the best time to call?

What is your business telephone number? -

 

 

 

ABOUT US SERVICES FACILITIES ADMISSIONS • EMPLOYMENT
NEWSEVENTSQUOTESDIRECTIONS CONTACT US

 
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