Equal Opportunity Employer - Connecticut Housing Partners



Equal Opportunity Employer

Connecticut Housing Partners is an equal opportunity employer to qualified individuals regardless of race, color, religious creed, age, sex, marital status, civil union, national origin, ancestry, physical or mental disability, mental retardation, learning disability, sexual orientation, genetic information, or any other legally protected class in accordance with all applicable laws.

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Personal Identification

______________________________________ ____________________________________

Name (Last, First, Middle Initial) Telephone (Home)

______________________________________ ____________________________________

Address (City, State, Zip Code) Telephone (Work or Cell)

______________________________________ ___________________________________

Date of Birth Social Security Number

General Information

Position Desired______________________________ When Can You Start?__________________________

Salary Desired_______________________________

Type of employment desired? Full Time □ Part Time □

Have you ever been terminated from any job? Yes □ No □ If yes, why? _________________________________________________________________________________________

_________________________________________________________________________________________

Are you legally eligible to work in the U.S.? Yes □ No □

Have you served in the military? Yes □ No □ If yes, what branch of the military________________

What is your current military status? Active □ Reserve (Active) □ Reserve (Inactive) □

Please list any other name(s) that you may have used in the past so that we may verify your work or educational

records. _____________________________________________________________________________________

Do you have a driver’s license in good standing? Yes □ No □

If no, please explain___________________________________________________________________________

State Issued_______________________ Driver’s License Number _____________________________________

Education Information

| | | | |

|Name and Address of School |Dates Attended |Did You Graduate |Degree/Major |

|High School |To___________ |Yes □ No □ | |

| |From__________ | | |

|Vocational /Business School |To___________ |Yes □ No □ | |

| |From__________ | | |

|College |To___________ |Yes □ No □ | |

| |From__________ | | |

|Graduate School |To___________ |Yes □ No □ | |

| |From__________ | | |

| | | | |

Special Skills or Qualifications:

________________________________________________________________________________________

_____________________________________________________________________________________

Professional Memberships/Certifications/Licenses:

__________________________________________________________________________________________

__________________________________________________________________________________________

Professional, Trade, Business or Civic Associations (exclude memberships which would reveal sex, race, religion, national origin, age, color, disability or other protected status)

_________________________________________________________________________________________

________________________________________________________________________________________

Employment History

List all previous employers starting with present or most recent. Account for all time for the last 10 years. Include periods of self employment, part-time and other jobs.) If more space is needed, attach a separate sheet of paper. Please complete all sections. Please attach resume to this form if available.

_____________________________________ _____________________________ _______________________

Name of Employer Address/City/State/Zip Employment Start/End

____________________________________ _____________________________

Employer Telephone Title or Position

May we contact your present employer? Yes □ No □_____________________________________

Employment History (continued)

_____________________________________ _____________________________ _______________________

Name of Employer Address/City/State/Zip Employment Start/End

____________________________________ _____________________________

Employer Telephone Title or Position

May we contact your present employer? Yes □ No □ ________________________________________

Name/Title of Immediate Supervisor

Description of Work/Responsibilities ______________________________________________________________

Employment History (continued)

_____________________________________ _____________________________ _______________________

Name of Employer Address/City/State/Zip Employment Start/End

____________________________________ _____________________________

Employer Telephone Title or Position

May we contact your present employer?  Yes □ No □ _____________________________

Name/Title of Immediate Supervisor

Description of Work/Responsibilities_____________________________________________________________

Employment History (continued)

_____________________________________ _____________________________ _______________________

Name of Employer Address/City/State/Zip Employment Start/End

____________________________________ _____________________________

Employer Telephone Title or Position

May we contact your present employer? Yes □ No □ __________________________

Name/Title of Immediate Supervisor

Description of Work/Responsibilities____________________________________________________________

Professional/Work References

Please list the names of two professional and one personal reference who have knowledge of your qualifications, skills and abilities.

|Name/Title |Relationship |Address/City/State/Zip |Telephone No./Email |

| | | | |

| | | | |

| | | | |

| | | | |

I hereby certify that the information provided on this application is true, correct and complete to the best of my knowledge. I understand that any material misrepresentation or deliberate omission of fact on this application may be sufficient cause to justify refusal of employment or once employed, may be cause for termination of employment. I understand that my employment may be contingent upon receipt of alien registration number, verification of birth and other pertinent information relating to my employment with Connecticut Housing Partners formerly MHASWCT. I further understand that my employment with Connecticut Housing Partners formerly MHASWCT is “at will” and may be terminated at any time with or without notice by myself or the employer.

_____________________________________________ _________________________

Applicant Signature Date

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