HCSO Application Step 1 of 3 33% Section Break Qualified applicants are considered for all positions without regard to race, color, religious creed, national origin, sex, genetic information, sexual orientation, ancestry, marital status or handicap, which does not preclude the applicant from performing the essential functions of the job with or without reasonable accommodation.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 subjected to criminal penalties and civil liability.Instructions: Please read the application for employment carefully and answer every question in full. If you cannot answer or do not understand any part of this application notify the Department representative immediately. In addition to the information required below, please provide any other information you think would be helpful to us in considering you for employment. You may exclude all information indicative of any status in the protected categories mentioned in the first paragraph.The minimum age requirement for full-time employment consideration is 21 years of age. Are you at least 21 years old?(Required) Yes NoDate of Application(Required) MM slash DD slash YYYY Email Do you belong to social network(s)? If so, please check applicable boxes: Facebook Twitter LinkedIn Instagram Select AllName(Required) First Middle LastAddress(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Cell Phone Number(Required)Home Phone NumberPosition(s) Applied for:(Required) Referred By: What is your minimum weekly salary requirement?(Required) Date you are available to start work?(Required) MM slash DD slash YYYY Education ListHigh School Name/AddressCourse of StudyYear CompletedDiploma Degree Add RemoveListUndergraduate School Name/AddressCourse of StudyYear CompletedDiploma Degree Add RemoveListGraduate School Name/AddressCourse of StudyYear CompletedDiploma Degree Add RemoveListOther (Specify) School Name/AddressCourse of StudyYear CompletedDiploma Degree Add RemoveIndicate any languages other than English you can speak, read and/or writeFluentGoodFair Add RemoveDescribe any specialized training, apprenticeship, skills, employment, or academic awards or honors and any extra-curricular activities that may relate to the position applied for(Required) Add RemoveIf you have ever served in the Armed Forces, Including the Reserves, complete the following: (Upon hire a copy of your DD214 is required)Branch: Type, Place and date of discharge: Any special training or skills: Duties performed: Reserve Obligations (list branch and unit): Employment Experience Start with your present or last job. Include any job-related military service assignments and volunteer activities. List all full-time and part-time employment held in the past ten years.1.EmployerAddressTelephone Number(s)Job TitleSupervisor Add Remove1.Reason for LeavingDates EmployedAvg.hrs. worked per weekWork Performed Add RemoveMay we contact this employer? Yes NoIf no, please give reason2.EmployerAddressTelephone Number(s)Job TitleSupervisor Add Remove1.Reason for LeavingDates EmployedAvg.hrs. worked per weekWork Performed Add RemoveMay we contact this employer? Yes NoIf no, please give reason3.EmployerAddressTelephone Number(s)Job TitleSupervisor Add Remove1.Reason for LeavingDates EmployedAvg.hrs. worked per weekWork Performed Add RemoveMay we contact this employer? Yes NoIf no, please give reason4.EmployerAddressTelephone Number(s)Job TitleSupervisor Add Remove1.Reason for LeavingDates EmployedAvg.hrs. worked per weekWork Performed Add RemoveMay we contact this employer? Yes NoIf no, please give reason5.EmployerAddressTelephone Number(s)Job TitleSupervisor Add Remove1.Reason for LeavingDates EmployedAvg.hrs. worked per weekWork Performed Add RemoveMay we contact this employer? Yes NoIf no, please give reason6.EmployerAddressTelephone Number(s)Job TitleSupervisor Add Remove1.Reason for LeavingDates EmployedAvg.hrs. worked per weekWork Performed Add RemoveMay we contact this employer? Yes NoIf no, please give reason7.EmployerAddressTelephone Number(s)Job TitleSupervisor Add Remove1.Reason for LeavingDates EmployedAvg.hrs. worked per weekWork Performed Add RemoveMay we contact this employer? Yes NoIf no, please give reason Additional Information Has any of the following happened to you in the last IO years? 1. Fired from a job? 2. Quit a job after being told you may be fired? 3. Left a job by mutual agreement following allegations of misconduct? 4. Left a job by mutual agreement following allegations of unsatisfactory performance or attendance’? 5. Left a job for other reasons under unfavorable circumstances.Click YES if any of these 5 events has occurred in the last 10 years: YES NOIf YESIf you answered YES to this question describe in detail when this occurred, what happened, the employer’s identity and a detailed explanation for each instance. (Use additional sheets as necessary.)ListPlease list any additional paid or volunteer work experience relevant to lhe position you are applying for.Should you be offered employment, would you consent to a medical examination and a drug test as a condition of employment, conducted solely for the purpose of determining whether you are, with reasonable accommodation, capable of performing the essential functions of the job?(Required) YES NO General Information (Please click yes or no) Have you ever served as an intern (shtdent internship) or volunteer here before? If yes, when and who was your supervisor?Untitled YES NOAre you presently on lay-off status subject to recall? YES NOHave you ever applied here before? If yes, when?Untitled YES NOHave you ever worked here before? If yes, when and why did you leave?Untitled YES NOAre you a United States citizen or authorized to work in the United States?(Required)You will be required to produce documentation to establish your identity and your authorization to work in the United States according with the Immigration Reform and Control Act of 1986. YES NOPerson To Notify In Case Of Emergency:(Required)Name: Telephone: AddressPersonal References(list three references not related to you that you have known for more than one (I) year)NameAddressPhone Number Add Remove2.NameAddressPhone Number Add Remove3.NameAddressPhone Number Add RemoveSmoking Statement: The Hampden County Sheriff’s Department has a NO SMOKING policy and does not allow smoking or the carrying of tobacco products or paraphernalia on any of it’s facility grounds, buildings or in any Department vehicles. Applicant’s Agreement Applicant’s Agreement To Release Records and Information Please read the following statements carefully I hereby affirm that I have read and understand this application and that the information that I have provided on this application (and accompanying resume, if any) is true and complete to the best of my knowledge. I agree that any omission or falsified information shall subject me to disqualification from further consideration for employment and shall be considered justification for my immediate dismissal if discovered at a later date. I hereby authorize all persons, schools, current employer (s) and other organizations named in this application (and accompanying resume, if any) to provide (The Hampden County Sheriff’s Department) with any relevant information that may be helpful in arriving at an employment decision. I hereby release, indemnify and hold harmless said persons and entities and (The Hampden County Sheriff’s Department) from any and all liability for providing and/ or using this information. This release shall be considered active for a period of one (1) year.Signature Date MM slash DD slash YYYY DISCLOSURE OF NAMES OF FAMILY MEMBERS WHO ARE STATE EMPLOYEES Disclosure Required by G.L. c. 268A, Sec. 6BName of Applicant for Employment: Date MM slash DD slash YYYY Is your spouse, parent, brother, sister or child, or the spouse of your parent, brother, sister or child, a state employee? YES NOIf you answered Yes, please list below the name(s) of any state employee who is your spouse, parent, brother, sister or child, or who is the spouse of your parent, brother, sister or child, and indicate their relationship to you. Please also list the name of the state agency that employs those relatives. NOTE: For purposes of this disclosure, a “state employee” is a person holding a paid or unpaid office, position, employment or membership in a Massachusetts state agency. For purposes of this disclosure, a “state agency” is any department of Massachusetts state government, including any department or agency within the executive, legislative or judicial branch, and all councils thereof and thereunder, and any division, board, bureau, commission, institution, tribunal or other instrumentality within such department or agency, and any independent state authority, commission, instrumentality or agency, but NOT INCLUDfNG an agency of a county, city or town.ListName of RelativeRelationship to ApplicantName of State Agency Add Remove
