Online Employment Application General/Contact Information Position: Accounts Receivable Asleep Overnight Assistant Manager Awake Overnight BA Clincian Bilingual Clinician Case Manager Clinical Coordinator CNA Data Entry Clerk Fee-for-Service Clinician Home Health Aide Human Rights Officer IFI Program Clinician IFI Worker Masters Level Clinician Office Manager On-Call Clinician Other - Specify to the right Program Director Residential Counselor Respite Coordinator Senior Clinician Senior Counselor Site Supervisor Support Worker Triage Coordinator Team Leader Other:  Last Name:       First Name:     Middle Initial:             Street Address:     City:     State:     Country     Zip Code         Phone: - Fax: - TTY: - Email Address: Are you over 18 years of age Yes   No   If no, please give date of birth Have you worked or previously applied to Advocates? Yes No If yes, when did you work or apply Before 1990 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Are you known by another name? Yes No If yes, what name Would you consider Relief/ on-call work? Yes No What was your referral source? School  Advertisement Advocates Employee  Walk-in  Newspaper Ad Employment Office Personal Contact  Surfing the Net Other Are you able to perform the essential requirements of the job?  Yes   No If no, are there reasonable accomodations that can be made to allow you to perform the essential functions of the job? If  you need any accommodation to facilitate the application process, please describe or contact The Office of Human Resources at (508) 628-6300, TTY (508) 935-0703  EDUCATION High School  State  City Country Years Completed  Graduated  or GED Rec'd   Yes No Date Rec'd College or University   State  City Country  Years Completed  Graduated   Yes  No  Date Rec'd Type of Degree Graduate or Technical Schools   State    City  Country  Years Completed  Graduated   Yes No Date Rec'd Type of Degree Do you have a valid driver's license? Yes No    Please list any professional, clinical or technical licenses.  For each, please list state of issue and date of expiration: Please list any job-related life experiences and skills you would like us to consider: WORK HISTORY Please list all previous work experience, giving most recent work history first. You may include in your work history any work performed on a volunteer basis Work History #1   May we contact your present employer? Yes No If no then why?    Employer  Position   Address City State  Zip Date Started Date Ended Starting Salary Ending Salary Name of last Supervisor Phone  - Major Duties: Reason for Leaving: Work History #2   May we contact your present employer? Yes No If no then why?    Employer  Position   Address City State  Zip Date Started Date Ended Starting Salary Ending Salary Name of last Supervisor Phone  - Major Duties: Reason for Leaving: Work History #3   May we contact your present employer? Yes No If no then why?    Employer  Position   Address City State  Zip Date Started Date Ended Starting Salary Ending Salary Name of last Supervisor Phone  - Major Duties: Reason for Leaving: PROFESSIONAL REFERENCES Reference #1 Name Title Relationship Address City State Zip Phone - Reference #2 Name Title Relationship Address City State Zip Phone - Reference #3 Name Title Relationship Address City State Zip Phone - CONVICTION INFORMATION An applicant with a sealed record of entries on file with commissioner of probation may answer "no record" to an inquiry about prior convictions of a crime.  In addition, any applicant for employment may answer "no record" to an inquiry relative to all cases of delinquency or as a "child in need of services" for which no criminal prosecution resulted. Have you ever been convicted of a felony?  Yes No If yes, please explain See CORI definitions for applicants for employment before responding to the next question Have you ever been convicted of a misdemeanor within the past 5 years?  Yes No If yes, please explain AFTER READING THE FOLLOWING, PLEASE SIGN BELOW: I certify that the information given in this application is true and complete to the best of my knowledge.  I understand that misrepresentation and/or withholding of information may result in the rejection of this application or my discharge if discovered after employment begins.  I authorize Advocates, Inc. to make inquiries of prior employers,  schools, or individuals from all liability in responding to inquiries in connection with my application, and release Advocates, Inc. from all liability with respect to such inquiries. I understand that if employed, I will be an employee "at will" and may be terminated at any time, with or without cause, and with or without notice at the option of either my employer or myself.  I also understand that no representative of the Agency, other than the President/CEO and/or his/her designee, has any authority to enter into any agreement for employment for any specific period of time or to make any agreement contrary to the foregoing and that such agreement must be made in writing.  If I am employed, I agree to abide by the Agency's policies, rules, and procedures and changes thereto. 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. 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