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Massachusetts job Application Form 3 Page 4
Massachusetts job Application Form 3
7/1/11
REFERENCES
Please list two references other than relatives or previous employers.
Name
Name
Position
Position
Company
____
Company
Address
Address
Telephone (
)
Telephone (
)
WAIVERS AND DISCLOSURES
Please read each section carefully and sign where indicated.
AT-WILL EMPLOYMENT
It is my understanding that this employment application, or the granting of an oral interview, does not represent a contract of
employment or a promise of future benefits by this organization. I understand and agree that, if hired, my employment will be at-will
in nature and may be terminated, with or without cause, at any time, by either myself or my employer. I also understand that this
written statement supersedes any and all oral representations made by agents or representatives of this organization.
CERTIFICATION OF TRUTH AND ACCURACY
I certify that the information in this application is true, complete and correct. I understand that false answers, statements, or significant
omissions made by me on this form shall be sufficient cause for denial of employment or discharge.
NOTIFICATION AND AUTHORIZATION TO REQUIRE A MEDICAL EXAMINATION
I hereby certify that, if hired, I will disclose any limitations I have that may impact my ability to do the job. I understand that I may also
be required to undergo a pre-employment or post-employment medical exam by the University’s designated health practitioner.
NOTIFICATION AND AUTHORIZATION TO CONDUCT BACKGROUND INVESTIGATION
I understand that I may be subject to a background check, and hereby authorize Justifacts Credential Verification, Inc. as an Agent
for Western New England University, to investigate my background to determine any and all information of concern as to my record,
whether same is of record or not, and I release employers and persons named in my application from all liability for any damages on
account of his/her furnishing said information.
Additionally, you are hereby authorized to make any investigation of my personal history, educational background, military record,
motor vehicle records, criminal records and credit history through an investigative or credit agency or bureau of your choice. I
authorize the release of this information by the appropriate agencies to the investigating service. This authorization, in original or copy
form, shall be valid for this and for any future reports and updates that may be required.
I understand that passing the background check is a condition of employment. A negative background check can be grounds for
dismissal, even if an offer has been made to me and I have been hired.
MASSACHUSETTS LAW
Under Massachusetts Law, 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.
PLEASE SIGN HERE:
Date
Non-Discrimination Policy: Western New England University is committed to the principle of equal opportunity in education and
employment. The University does not discriminate on the basis of sex, race, color, creed, national origin, age, religion, sexual
orientation, gender identity, gender expression, veteran status, or disability in admission to, access to, treatment in, or employment in
its programs and activities.
The following person has been designated to handle inquiries regarding the University’s nondiscrimination policies: Assistant Vice
President and Director of Human Resources, Western New England University, 1215 Wilbraham Rd., Springfield, MA 01119-2684.
Inquiries concerning the application of nondiscrimination policies may be also referred to: Office for Civil Rights, Boston Office, U.S.
Department of Education, 33 Arch Street, Suite 900 Boston, MA 02110 (617) 289-0111 FAX# (617) 289-0150; TDD (617) 223-9695 or
at www.ed.gov.
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