Hale Barnard Employment Application Please enable JavaScript in your browser to complete this form. - Step 1 of 111. Employment InformationName *FirstMiddleLastIs there another name under which you have worked and/or attended school that we should use when making inquiries on your behalf?FirstLast(other name)Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeLength of Time at This AddressPhone *Telephone Number where you can be reached during the dayBest time to reach you1. Address *Address Line 1City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeList your last three addresses, during the past five years. (Within the United States do not include Military Service)2. Address *Address Line 1City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeList your last three addresses, during the past five years. (Within the United States do not include Military Service)3. Address *Address Line 1City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeList your last three addresses, during the past five years. (Within the United States do not include Military Service)Next2. Job InformationPosition applying forSalary requirementsCheck oneFull-TimePart-TimeIf part-time, hours availableHow were you referred to this agency? AgencySchoolMailEmployeeNewspaper AdWalk InOtherName (of agency, employee, newspaper)Date available for workDo you have the legal rights to work in the United States? YesNo3. Employment HistoryStarting SalaryFinal SalaryCompany NameJob TitleDate FromDate ToAddressSupervisorFirstLastPhoneCheck one (copy)Full-TimePart-TimeJob DutiesReason for LeavingStarting SalaryFinal SalaryCompany Name Job Title Date From Date To Address Supervisor FirstLastPhone Check one (copy) (copy)Full-TimePart-TimeJob Duties Reason for Leaving If you are now employed, may we contact your present employer? ImmediatelyAfter offer of employmentMay we contact former employers?YesNoPreviousNext4. Education RecordHigh School or Preparatory NameAddress, City, StateYear Completed1234Graduate?YesNoMonth/YearBusiness School Name Address, City, StateMajor CourseYear Completed 1234Major/SubjectGraduate? YesNoMonth/Year DegreeCollege Name Address, City, StateMajor CourseYear Completed 1234Major/Subject Graduate? YesNoMonth/Year Degree Graduate work - NameAddress, City, StateMajor Course Year Completed 1234Major/Subject Graduate? YesNoMonth/Year DegreePreviousNext5. Security InformationIn answering the following questions, you may omit any information or answer “no record” with regard to any conviction for which there is a sealed record on file with the Commissioner of Probation. You should also omit first convictions for drunkenness, simple assault, speeding, minor traffic violations, affray or disturbance of the peace.1. Have you ever been convicted of a felony?YesNoif yes, give dates and details2. Have you been convicted of a misdemeanor within the last five years?YesNo3. If your answer to question 2 above is yes, or if you have been convicted of a felony within the last five years, give the date and details of any misdemeanor for which you were convicted more than five years ago.PreviousNextPLEASE READ BEFORE SIGNING(If you have any questions regarding this statement, please ask the employment interviewer before signing.) It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. Any employer who violates this law shall be subject to criminal penalties and civil liability. For this reason Hale Barnard uses only legally permissible means to investigate the truthfulness of statements made by employees and applicants for employment. Hale Barnard is committed, in accordance with applicable law, to a policy of nondiscrimination and equal opportunity for all employees and qualified applicants, without regard to race, color, religious creed, national origin, ancestry, sex, marital status, sexual preference, age, handicap or status as a disabled or Vietnam-era veteran. I understand that any offer of employment may be conditioned upon a medical examination by a doctor selected by Hale Barnard, to which I hereby consent. I understand that upon employment I must provide proof of employment authorization and proof of identity. Failure to do so in accordance with federal specifications will result in immediate employment termination. In the event of my employment by Hale Barnard Corporation, I will comply with all rules and regulations as set forth in company policy manuals and other communications to employees, as they may be changed from time to time. I agree to give Hale Barnard two weeks’ notice of resignation, but understand that my employment is for no stated term and is subject to termination at the will of Hale Barnard. I certify that all statements made by me on this application are true and complete to the best of my knowledge and that I have withheld nothing that, if disclosed, would affect this application unfavorably. I UNDERSTAND THAT FALSIFICATION, MISREPRESENTATION OR OMISSION OF FACTS CALLED FOR IN THIS APPLICATION MAY RESULT IN DENIAL OF EMPLOYMENT OR IMMEDIATE DISMISSAL. I hereby acknowledge that I have read, understand and consent to the above statements.SignatureClear SignatureI hereby acknowledge that I have read, understand and consent to the above statements.Date PreviousNextPLEASE COMPLETE ONE FORM FOR EACH SCHOOL YOU HAVE ATTENDEDFor the purpose of determining by eligibility for employment by Hale Barnard, I hereby authorize the following educational institution to provide any records relating to my academic record, class standing, graduation and attendance record to Hale Barnard Corporation or to any person, firm or entity acting as the agent for said CorporationName of SchoolStreet or Mailing AddressAddress Line 1City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeHigh SchoolUndergraduateGraduate SchoolAccounting/Business SchoolNurse’s Aide TrainingNursing SchoolComputer Training ProgramDates AttendedYear GraduatedDate SignatureClear SignatureSignature of Parent if under 18Clear SignatureHale BarnardHale Barnard Corporation hereby certifies that the records indicated above are to be used for the purpose of determining the eligibility of the applicant for employment. This form may be retained with your file on the applicant for inspection by the student or parents of the students.By:PreviousNextPLEASE COMPLETE ONE FORM FOR EACH SCHOOL YOU HAVE ATTENDED For the purpose of determining by eligibility for employment by Hale Barnard, I hereby authorize the following educational institution to provide any records relating to my academic record, class standing, graduation and attendance record to Hale Barnard Corporation or to any person, firm or entity acting as the agent for said CorporationName of SchoolStreet or Mailing Address Address Line 1City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeHigh SchoolUndergraduateGraduate SchoolAccounting/Business SchoolNurse’s Aide TrainingNursing SchoolComputer Training ProgramDates Attended Year Graduated Date SignatureClear SignatureSignature of Parent if under 18 Clear SignatureHale Barnard Hale Barnard Corporation hereby certifies that the records indicated above are to be used for the purpose of determining the eligibility of the applicant for employment. This form may be retained with your file on the applicant for inspection by the student or parents of the students.By: PreviousNextPLEASE COMPLETE ONE FORM FOR EACH SCHOOL YOU HAVE ATTENDED For the purpose of determining by eligibility for employment by Hale Barnard, I hereby authorize the following educational institution to provide any records relating to my academic record, class standing, graduation and attendance record to Hale Barnard Corporation or to any person, firm or entity acting as the agent for said CorporationName of School Street or Mailing Address Address Line 1City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeHigh SchoolUndergraduateGraduate SchoolAccounting/Business SchoolNurse’s Aide TrainingNursing SchoolComputer Training ProgramDates AttendedYear Graduated Date SignatureClear SignatureSignature of Parent if under 18 Clear SignatureHale Barnard Hale Barnard Corporation hereby certifies that the records indicated above are to be used for the purpose of determining the eligibility of the applicant for employment. This form may be retained with your file on the applicant for inspection by the student or parents of the students.By: PreviousNextPLEASE COMPLETE ONE FORM FOR EACH SCHOOL YOU HAVE ATTENDED (copy)For the purpose of determining by eligibility for employment by Hale Barnard, I hereby authorize the following educational institution to provide any records relating to my academic record, class standing, graduation and attendance record to Hale Barnard Corporation or to any person, firm or entity acting as the agent for said CorporationName of School Street or Mailing Address Address Line 1City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeHigh SchoolUndergraduateGraduate SchoolAccounting/Business SchoolNurse’s Aide TrainingNursing SchoolComputer Training ProgramDates Attended Year Graduated Date SignatureClear SignatureSignature of Parent if under 18 Clear SignatureHale Barnard Hale Barnard Corporation hereby certifies that the records indicated above are to be used for the purpose of determining the eligibility of the applicant for employment. This form may be retained with your file on the applicant for inspection by the student or parents of the students.By: PreviousNextAUTHORIZATIONI hereby authorize Hale Barnard Corporation, its employees and agents, including Standard research, inc., to make inquiry of and request information from, any individuals, present and former employers, schools and colleges, credit bureaus, and any other entities that may possess information concerning me or that may be custodians or records relating to me. I also authorize the abovedescribed sources to release all information requested, including salary date and subjective evaluations, and I hereby release those sources from any liability for doing so.SignatureClear SignatureName (Please Print)Date REFERENCE RELEASE FORMI hereby authorize Hale Barnard to make employment and/or reference inquiries it deems necessary in connection with my employment application to the below listed individuals. I authorize and instruct any person listed below to compile and furnish any information it may have or obtain in response to employment. I authorize this document to be reproduced by a copy machine and/or faxed. All information obtained shall remain confidential and will not be used for any other purpose.Single Line TextReference 1 - NameFirstLastPhoneReference 2 - Name *FirstLastCompanyPhone Reference 3 - Name *FirstLastCompanyPhone PreviousNextAPPLICATION FOR EMPLOYMENTAll applicants are asked to complete a standard employment application form; each applicant’s qualifications will be screened, and his/her references checked. Misleading or false information given by an applicant, and the omission of material information that should be stated, may result in dismissal. Hale Barnard has been certified by the Criminal History Systems Board to obtain conviction records and information regarding pending court activity of volunteers and current and prospective employees in accordance with the law governing elder care. In compliance with state law, in order to be employed at Hale Barnard every candidate must undergo a criminal background & security check and no hiring decisions will be made until the results come back.MessageSubmit