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  We consider applicants for all positions without regard to age, race, color, religious creed, national origin, sex, sexual orientation, age, criminal record, mental illness, handicap/disability, or any other legally protected status pursuant to Massachusetts Fair Employment Practices Act, and other relevant federal, state and local laws.
 

Position Applied For 

Date of Application 

How Did You Learn About Us?
Advertisement    If so, which one
Referred by friend or relative
Sign in front of building
Employment Agency    If so, which one
Other    If so, which one

Name (last, first) 

Street Address    
City                       State   Zip
Telephone          
E-mail address   

When is the best time to reach you?
Morning     Afternoon     Evening     Night

What factors led you to be interested in this job?  (check all that apply)
Pay and overtime possibilities
Nature of the work
You state that there are good advancement opportunities
I'd like to be trained in behavior modification procedures
The benefits seem to be good
Other (please specify)

If you are interested in advancement within JRC, what jobs or departments would you like to advance to? (check all that apply)
Weekday Classroom Coordinator
Residential Coordinator
Monitor
Trainer
Case Manager
Director of Evening, Overnight, or Weekend
Quality Control
Assistant to Director for Treatment
Teacher Trainee
Certified Teacher
Administrative Assistant Education
Director of Precision Teaching
Administrative Assistant Student Services
Nursing Assistant
Administrative Assistant Bookkeeping
Clothing Coordinator
Charter
Recruitment and Human Resources
Admissions and Marketing

If you are under 18 years of age, can you provide required proof of your eligibility to work?
  Yes          No         Over 18

Have you ever filed an application with us before?
  Yes          No        If yes, give date 

Have you ever been employed with us before?
  Yes          No        If yes, give date 

Are you currently employed?      Yes          No

If so, may we contact your present employer?      Yes          No

Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status? Proof of citizenship or immigration status will be required upon employment.
  Yes          No

On what date would you be available for work?   

Are you available to work:    Full Time    Part Time    Shift Work    Temporary

Are you currently on "lay-off" status and subject to recall?      Yes          No

Have you been convicted of a felony?      Yes          No

If yes, please explain 

Within the last 5 years have you been convicted of, or released from incarceration for a misdemeanor which was not a first offense for drunkenness, simple assault, speeding, a minor traffic violation, an affray, or disturbing the peace?      Yes          No

If yes, please explain 

Education

High School
Name and Address of School 

Diploma Awarded?  Yes     No

Undergraduate College
Name and Address of School 

Course of Study 

Degree Awarded? 

Graduate/Professional
Name and Address of School 

Course of Study 

Degree Awarded? 

Other (Specify)
Name and Address of School 

Course of Study 

Diploma/Degree (specify) 

Indicate any foreign languages you can speak, read and / or write

Speak
Fluent Good Fair

Read
Fluent  Good Fair

Write
Fluent Good Fair

Check off any special job-related skill and/or qualification you have. (Check all that apply)
Computer Skills (specify)     
Software Skills (specify)       
Audiovisual Skills (specify)   
Musical Skills (specify)         
Other (specify)                     

Certification

If you are applying for a teaching position please answer the following questions:

Are you certified?  N/A     Yes     No 

What is your certification level? 

What state do you hold your certification in? 

Employment Experience

Start with your present or last job. Include any job-related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities or other protected status.

1.
Employer      

Address             
City                       State   Zip
Telephone          

Job Ttile      
Supervisor   
Reason for leaving    

Dates Employed        From      To 

Hourly Rate/Salary     Starting    Final 

Work Performed

2.
Employer      

Address             
City, State, Zip      State    Zip
Telephone          

Job Ttile      
Supervisor   
Reason for leaving    

Dates Employed        From      To 

Hourly Rate/Salary     Starting    Final 

Work Performed

3.
Employer      

Address             
City, State, Zip      State   Zip
Telephone          

Job Ttile      
Supervisor   
Reason for leaving    

Dates Employed        From      To 

Hourly Rate/Salary     Starting    Final 

Work Performed

4.
Employer      

Address             
City, State, Zip      State   Zip
Telephone          

Job Ttile      
Supervisor   
Reason for leaving    

Dates Employed        From      To 

Hourly Rate/Salary     Starting    Final 

Work Performed

Additional Information

State any additional information you feel may be helpful to us in considering your application.

Note to Applicants:  DO NOT ANSWER THIS QUESTION UNLESS YOU HAVE BEEN INFORMED ABOUT THE REQUIREMENTS OF THE JOB FOR WHICH YOU ARE APPLYING.

Are you capable of performing in a reasonable manner, with or without a reasonable accommodation, the activities involved in the job or occupation for which you have applied?
  Yes          No

Additional Notes:

 

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