Employee Application

As an Equal Opportunity Employer, PCI Synthesis, Inc. does not discriminate in hiring or terms and conditions of employment because of an individual's race, creed, color, sex, sexual orientation, age, national origin, ancestry, handicap, marital status or military status.

NOTE

Use of Lie Detector

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.

Volunteer Work

Applicants may include any verified work performed on a volunteer basis in the "Employment Record" section of the form.

Work Authorization

Proof of an individual's legal authorization to work in the United States will
be required at the time of hire.

Pre-employment Physical

All offers for employment are contingent on the applicant passing a
pre-employment physical which includes drug testing.

Personal Information
Name (First,Last, MI):
Current Address:
Address:
City:
Postal Code:
State or Province:
If you have lived at the above address less than 12 months, list previous address:
Address:
City:
Postal Code:
State or Province:
Telephone:
Home:
Work:
Email:
Position or Area of Employment Desired
Salary Requirements:
Are you legally authorized to accept employment in this country?: Yes No (Proof of citizenship or immigration status will be required upon employment.)
If employed and you are under 18, can you furnish a work permit? Yes No
Have you ever been convicted of a felony? Yes No
If Yes, Where:
Disposition of Case:
The company does not require that you furnish, and will not make or keep a record of any criminal information prohibited by Massachusetts G.L. c.151B §4(9). An applicant for employment with a sealed record on file with the Commissioner of probation may answer “NO RECORD” with respect to the inquiry herein relative to prior arrests, criminal court appearances or convictions. In addition, any Applicant for employment may answer “NO RECORD” with respect to any prior arrests, court appearances and adjudications in all cases of delinquency or as a child in the need of services, which did not result in a compliant transferred to the Superior Court for criminal prosecution.
Education
Name of School:
Location:
Graduate:	Yes No
Major:
Degree:	Select... Bachelors Masters Doctorate Other None
Honors Received:
U.S. Military Service
Have you Served in the Military: Yes No
Date of Service:
Date and Place of Discharge:
Employment Record
Name of Company:
Dates of Employment:
Address:
City:
Postal Code:
State or Province:
Type of Business:
Job Title(s):
Supervisor Name and Title:
Department:
Base Rate of Pay:
Additional Compensation:
Reason for Leaving:
Description of Your Duties:
Previous Employment
Name of Company:
Dates of Employment:
Address:
City:
Postal Code:
State or Province:
Type of Business:
Job Title(s):
Supervisor Name and Title:
Department:
Base Rate of Pay:
Additional Compensation:
Reason for Leaving:
Description of Your Duties:
Name of Company:
Dates of Employment:
Address:
City:
Postal Code:
State or Province:
Type of Business:
Job Title(s):
Supervisor Name and Title:
Department:
Base Rate of Pay:
Additional Compensation:
Reason for Leaving:
Description of Your Duties:
References
Name:
Relationship:
Company:
Position:
Work Phone:
Home Phone:
Name:
Relationship:
Company:
Position:
Work Phone:
Home Phone:
Name:
Relationship:
Company:
Position:
Work Phone:
Home Phone:
Employment Agreement
I certify the forgoing to be, to the best of my knowledge and belief, an accurate and true statement of fact. It is fully understood that any false statements or misrepresentations by me will be sufficient reason for dismissal from the services of the Company. I hereby authorize investigation of all statements contained in this record. In making application for employment, I understand and agree that: This application does not constitute a contract of employment and I further understand that if hired, my employment IS "AT-WILL", is for no specified period of time, and may be terminated at any time, with or without cause, by myself or the Company.
Check this box to certify that you have read and accept the above statement. Yes
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