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CAREERS

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Availability: check all that you could work

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Evening hours (5-9 PM)
Nights (9-12 Midnight)
Overnight
Live-in

DATE OF APPLICATION

DATE  AVAILABLE FOR EMPLOYMENT

TYPE OF EMPLOYMENT DESIRED

Per Diem
Full Time
Part Time

POSITION APPLYING FOR

FIRST NAME

LAST NAME

MAILING ADDRESS

CITY

STATE

ZIP CODE

HOME PHONE NUMBER

WORK PHONE NUMBER

CELL PHONE NUMBER

EMAIL ADDRESS

LANGUAGE SKILLS OTHER THAN ENGLISH

DATE OF BIRTH

HAVE YOU EVER BEEN EMPLOYED BEFORE?
NO
YES

REFERRAL INFORMATION

HOW DID YOU HEAR ABOUT US?

Newspaper Advertisement
Internet
Current Employee
Other

EMERGENCY CONTACT INFORMATION

NAME

RELATIONSHIP

HOME PHONE NUMBER

WORK PHONE NUMBER

CELL PHONE NUMBER

Merrimack Institute LLC is an equal opportunity employer. All applicants and employees are considered for employment,advancement, and development based upon their skills, perfomance and potential. No current or prospective employee will be discriminated against because of race, creed, color, gender, age, national origin, handicap, or military status.

EMPLOYMENT HISTORY-Please begin with your most recent or current plave of employment

PLACE OF EMPLOYMENT

START DATE

ADDRESS

END DATE

POSITION

PHONE NUMBER

SUPERVISOR

REASON FOR LEAVING

EDUCATION

HIGH SCHOOL

YEARS COMPLETED

LOCATION

DATE GRADUATED

COLLEGE

YEARS COMPLETED

LOCATION

DATE GRADUATED

OTHER

YEARS COMPLETED

LOCATION

DATE GRADUATED

MILLITARY SERVICES

BRANCH OF SERVICE

HIGHEST RANK ACHIEVED

DATE OF SERVICE

CURRENTLY IN A RESERVE UNIT?
YES
NO

SPECIAL SCHOOLING OR DUTIES

LICENSE AND CERTIFICATIONS

LICENSE OR CERTIFICATIONS

EXPIRATION DATE

ID NUMBER

STATE

CRIMINAL HISTORY

HAVE YOU EVER BEEN COVICTED OF VIOLATING ANY LAW? (Please omit minor traffic violations.)

YES

EMPLOYEE CANDIDATE NAME

NO

DATE

REFERENCE FORM

COMPANY NAME

ADDRESS

PHONE

THE INDIVIDUAL LISTED BELOW HAS APPLIED FOR A POSITION IN MERRIMACK INSTITUTE LLC

LAST NAME

FIRST NAME

MIDDLE NAME

THE POSITION BEEN APPLIED FOR IS

APPLICANT'S AUTHORIZATION TO RELEASE INFORMATION

I hereby give permission for my previous employer to release this referral information about my position with their company and comments regarding my work ethic and character while in their employ

APPLICANT NAME

DATE

THIS SECTION TO BE COMPLETED BY PERSON COMPLETING THIS FORM

Employment Dates:

FROM

TO

POSITION

REASON FOR SEPARATION

WOULD YOU RE-HIRE?

 YES
 NO

Since this applicant has given your company as a former employer, we would consider it a favor both to us, if you would give us your opinion. We all strive to minimize employee turnover and a frank exchange of information can substantially assist in accomplishing this objective. We would greatly appreciate your answers to the following questions in the same way you would request us to complete a similar form for you.

EVALUATION

ATTENDANCE

Excellent
Good
Average
Poor

QUALITY OF WORK

Excellent
Good
Average
Poor

INTEGRITY

Excellent
Good
Average
Poor

COOPERATION

Excellent
Good
Average
Poor

DEPENDABILITY

Excellent
Good
Average
Poor

APPEARANCE

Excellent
Good
Average
Poor

STABILITY

Excellent
Good
Average
Poor

COMMENTS

TITLE OF REFERENCE

DATE

CONTACT US

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Contact Details

978.710.9307 | Fax: 978.616.7210 Email Address: admin@timkihiko.com
55 middlesex st north chelmsford ma

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Phone 978.710.9302 | Fax: 978.616.7210  Admin@timkihiko.com
55 Middlesex St, North Chelmsford MA 01863

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