Employment Opportunities

Request Form

Name*

Date*

Address*

Phone*

Are you a United States citizen?*

If no, what is your status?

Free Text

Do you have any physical conditions that may prohibit you from heavy lifting duties?*

Back*

Yes

Knees*

Yes

Neck*

Yes

Shoulder*

Yes

Other

If yes to any of these conditions, please explain below.

Do you currently use illegal drugs or have used drugs in the past year?

If yes, please explain below.

Have you ever been arrested, or convicted of a crime? If yes, please explain below.

Please give a brief description of your education, beginning with your most recent. Be sure to include the name of your high school (or equivalency), college or university and the years you attended the institution.

Please explain any job experiences or special skills that you feel contribute to your application for this position. Be sure to include your most recent job experiences. Also include the name of the employer, the length of employment, dates employed and the reason for leaving.

Please list at least two references and the phone number that they can be contacted. References should not include family or relatives.

Please list any and all driving violations that you have received in the last 3 years.

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Connecticut and Berkshire County, MA

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