Application for Employment
An Equal Opportunity/Drug-Free Employer
We are an equal opportunity employer and do not discriminate against any applicant because of race, color,
religion, sex, national origin, age, disability, sexual orientation, marital status, or any other class protected by federal,
state or local law. It is unlawful 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 Return to:
MassDevelopment Finance Agency
ATTN: Human Resources
99 High Street, 11th Floor
Boston, MA 02110
or
Fax: (617) 603-3112
E-mail: jobs@massdevelopment.com
99 HIGH STREET, 11TH FLOOR
BOSTON, MA 02110
Personal Data
Name: Last__________________________________ First:
Middle: ________________
Current Address: Street: ________________________________________________________________________
City: _________________________________________ State: ___________________ Zip: ___________________
Day Phone Number: (
) ______ - ____________ Evening Phone Number: (
) ______ - ____________
How or by whom were you referred? ________________________________________________________________
Position Desired: _______________________________________________________________________________
Have you applied at MassDevelopment before?
Yes
If you are under 18, could you furnish a work permit?
No If yes, give dates: ____________________________
Yes
Are you legally authorized to work in the United States?
No
Yes
I am over 18
No
(if hired, you will be required to submit proof of your identity and legal work authorization as a condition of employment.)
Do you have any relatives employed at MassDevelopment?
Yes
No
If yes, give name and location employed: ____________________________________________________________
Have you ever been employed by MassDevelopment?
Yes
No
If yes, give dates and location employed: _____________________________________________________________
Do you have specific salary requirements?
Yes
No If yes, please indicate: _____________________________
Employment Data
Date available for work: ______________________________ Total hours available per week: _________________
Type of hours:
full time
part time
regular
temporary* * what date will you no longer be available to work: __________________
Will you work overtime if necessary?
days*
Yes
nights* * Hours available: ___________________________
No If yes, how many hours per week? ______________________
Are there any days or hours you are unable or unwilling to work? __________________________________________
Do you have transportation to and from work?
Yes
No
What is the most amount of time you wish to spend commuting to work? ____________________________________
Will you travel?
Yes
Are you willing to relocate?
No If yes, what percent of your time? ________________________________________
Yes
No If yes, where? _______________________________________________
Education
High School: Name:_____________________________________ City: ___________________________ State:_______
Diploma or GED:
yes
no
College (list all whether or not degree was obtained)
Name
Address
Major
Minor
Degree
Academic honors, awards or special recognition: _________________________________________________________
Other night school, correspondence, home study or courses not listed above: ___________________________________
________________________________________________________________________________________________
Yes
No
Do you have any objection to our contacting your previous schools?
If yes, explain: _____________________________________________________________________________________
Professional Licensees
If you are applying for a position that requires a professional licenses, do you have a current license to practice in
Massachusetts:
Yes
No
If yes, what please indicate type: _______________________________________________________________________
(If you are applying for a position that requires operating a commercial vehicle, you MUST have a Massachusetts
Commercial Drivers License)
Employment Record Information
Current/Most Recent Employer:_____________________
Type of Business:________________________________
Address: ______________________________________
Supervisors Name: ______________________________
Duties/Responsibilities:
______________________________________________
Employer:_____________________________________
Type of Business:_______________________________
Address: ______________________________________
Supervisors Name: ______________________________
Duties/Responsibilities:
______________________________________________
Employer:______________________________________
Type of Business:________________________________
Address: ______________________________________
Supervisors Name: ______________________________
Duties/Responsibilities:
______________________________________________
Employment Dates: ________________________________
Job Title: ________________________________________
Salary: ____________________ per __________________
Bonus/ Incentive:__________________________________
Reason for leaving: ______________________________
Company phone number: ( ) ____________
Yes
No
May we contact?
Employment Dates: ________________________________
Job Title: ________________________________________
Salary: ____________________ per __________________
Bonus/ Incentive:__________________________________
Reason for leaving: ______________________________
Company phone number: ( ) ____________
May we contact?
Yes
No
Employment Dates: ________________________________
Job Title: ________________________________________
Salary: ____________________ per __________________
Bonus/ Incentive:__________________________________
Reason for leaving: ______________________________
Company phone number: ( ) ____________
May we contact?
Yes
No
Medical
I understand that any offer of employment with MassDevelopment will be contingent upon my successful completion of any
post offer, pre-employment physical examination that MassDevelopment may require. I also understand and agree that I
may be required to undergo and successfully pass a screening for alcohol and/or drugs during the hiring process and, if
employed, as required by the agency.
Signature: ______________________________________________
Signature
Please read the following carefully before signing:
1. I understand that the receipt of this application does not imply that I will be employed.
2. The statements and information furnished by me in this application are true and complete. I understand that I will
be subject to immediate dismissal or refusal to hire if at any time MassDevelopment discovers any material
falsification, omission or misrepresentation of fact in this application.
3. I authorize MassDevelopment to conduct a background inquiry to verify the statements and information on this
application, other documentation that I have provided and other areas that may include prior employment,
consumer credit, criminal convictions, motor vehicle history and other reports. I authorize all previous employers or
other persons who have knowledge of me, or my records to release such information to MassDevelopment. I
hereby release any individual, agency and MassDevelopment from all claims or liabilities whatever that may arise
from the disclosure of such information.
4. I understand that I may be required, depending upon my position, to sign a non-compete, confidentiality and/or
business ethics agreement as a condition of my employment.
5. I understand that all employees of MassDevelopment are employees at will. If hired, I will be free to resign at any
time. Likewise, MassDevelopment will have the right to terminate my employment at any time with or without any
reason or notice, regardless of the date of payment of my wages or salary. Neither this application, the Employee
Handbook or any other documents given to employees is intended to create nor should such documents be
constructed as creating, an express or implied contract.
6. Any offer of employment is contingent upon favorable results from background and reference checks.
My signature certifies that I have read the above statement:
Signature of Applicant: __________________________________________________ Date: _______________
References
Name: Last__________________________________ First:____________________ Middle: ________________
Position Applied for: _____________________________________ Location: _____________________________
Professional References
Please list three professional references who can verify your work history and performance. References should
not be relatives and at least two must have directly supervised you at some point in your work history.
1. Name of Supervisor: ___________________________________ Title:____________________________________
Company Name and Address:_____________________________________________________________________
Company Phone Number (include area code and extension): ____________________________________________
2. Name of Supervisor: ___________________________________ Title:____________________________________
Company Name and Address:_____________________________________________________________________
Company Phone Number (include area code and extension): ____________________________________________
3. Name of Supervisor: ___________________________________ Title:____________________________________
Company Name and Address:_____________________________________________________________________
Company Phone Number (include area code and extension): ____________________________________________
Personal References
Please list two personal references. Personal references should not be relatives.
1. Name :_______________________________________ Telephone Number: ______________________________
Address: _____________________________________________________________________________________
Occupation: __________________________________ Years Acquainted:____________________
How do you know this individual? _________________________________________________________________
2. Name :_______________________________________ Telephone Number: ___________________________
Address: _____________________________________________________________________________________
Occupation: __________________________________ Years Acquainted:____________________
How do you know this individual? _________________________________________________________________
99 HIGH STREET, 11TH FLOOR
BOSTON, MA 02110
NOTICE & CONSENT FOR THE PROCUREMENT OF A CONSUMER AND/OR
INVESTIGATIVE REPORT FOR EMPLOYMENT PURPOSES
I, the undersigned consumer, do hereby authorize MassDevelopment to procure a consumer report
and/or investigative consumer report on me. I understand that MassDevelopment may utilize a
consumer-reporting agency to perform this service.
I understand that the above-mentioned reports may include, but are not limited to, information concerning
my employment history, education, character, general reputation, credit history, judgments, liens, driving
history, social security number, criminal/civil history and any other public records.
I understand such information may be obtained by direct or indirect contact with former employers,
schools, financial institutions, landlords, public agencies as well as through personal interviews with my
references, associates, or other persons who may have such knowledge.
I understand that upon written request, I will be informed whether or not an investigative report was
requested, and if a report was requested, I will be informed of the name and address of the consumer
reporting agency that furnished the report.
I understand that this consumer report or investigative consumer report will be utilized by
MassDevelopment for the purposes of evaluating me for employment, retention, promotion or
reassignment. I also understand that if I am denied employment or adverse employment action is taken
against me based wholly or in part on information obtained from this consumer report, that I will be notified
by MassDevelopment. In such event, MassDevelopment will provide me with a copy of the consumer
report along with a description of my rights under the Fair Credit Reporting Act and applicable state and
federal laws.
I hereby release MassDevelopment, its agents, and any and all persons, business entities and
governmental agencies, whether public or private, from any and all liability, claims and/or demands, by
me, my heirs or others making such a claim or demand on my behalf, for providing a consumer report
and/or investigative consumer report hereby authorized. I understand that this Notice & Consent form
shall remain in effect for the duration of my employment with MassDevelopment and shall serve as
ongoing authorization to procure a consumer report at any time during the course of my employment.
Printed Name: ____________________________________________________________________
Signature:
_____________________________________ Date: __________________________
Release & Authorization
I hereby authorize, without reservation, Creative Services, Inc. of 64 Pratt Street, Mansfield, MA 02048-1927, (800) 5360093 or (508) 339-5451 and its agents to conduct a full investigation into my background and activities at any point after
this authorization and, if hired, throughout my employment. Therefore, I hereby authorize the release of any and all
information pertaining to me, documentary or otherwise, as requested by any appropriate employee, agent or
representative of Creative Services, Inc. I understand that during this background investigation process and in
accordance with the Fair Credit Reporting Act, a “consumer report,” “consumer credit report,” and/or “investigative
consumer report” (consumer report) may be obtained concerning my character, general reputation, personal
characteristics, and mode of living. The nature and scope of my investigation may include but is not limited to
employment, credit, education, criminal, and driving history. I release all courts, probation departments, selective service
boards, employers, educational institutions, banks, credit bureaus, financial and other institutions, law enforcement and
local, state (including the Minnesota Bureau of Criminal Apprehension), and federal government agencies without
exception, both foreign and domestic to furnish any and all background information (including, but not limited to, driving
and/or motor vehicle records) requested by Creative Services, Inc. I understand that this information may be transmitted
electronically and authorize such transmissions. I agree that a photocopy of this release shall be accepted with the same
authority as the original. CSI's Privacy Policy can be found at http://www.creativeservices.com/html/privacy_policy.html or
obtained by request to the above address.
California, Minnesota, and Oklahoma applicants or employees only: Please check this box if you would like a copy
of the consumer report if one is prepared on you?

 YES
If currently employed, may we contact your current employer?
 NO  N/A
(Last Name)
(First Name)
(Middle Name)
(Other Names)List all other NAMES (including maiden or married names) utilized during the previous 7 years and/or used when obtaining any
degrees or certifications.
Current Address:
City & State:
Social Security Number:*
Zip Code:
Date of Birth: *
MM/DD/YYYY
Driver’s License Number:*
State of Issue:
Please list all addresses where you have resided for the past seven years:
(#/Street)
(City)
(State)
(Zip Code)
(#/Street)
(City)
(State)
(Zip Code)
(#/Street)
(City)
(State)
(Zip Code)
(#/Street)
(City)
(State)
(Zip Code)
Signature:
Date:
* Social security numbers, dates of birth, and drivers’ license numbers are requested to ensure accurate retrieval of records. They will not be
considered by the employer in making employment decisions. This form will be filed separately from your employment application.