Employment Application

Personal Information

Invalid email address Preferred Communication Method: Are you at least 18 years old? Are you authorized to work in the United States? Do you have a valid drivers licence? Do you have a car available? Additional Languages Spoken:

By providing my mobile phone number, I give Anodyne, the Company, permission to send text messages to my mobile phone. I understand that text messaging rates may apply to any messages received from the Company. I also understand that I, or the Company, may revoke this permission in writing at any time. I agree not to hold the Company liable for any electronic messaging charges or fees generated by this service. I further agree that in the event my contact/mobile phone number changes, I will inform the Company. This authorization will remain in effect until revoked in writing by me or the Company. Your information will be used only by the Company and will not be shared or distributed in any way.

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By providing my email address, I give Anodyne, the Company, permission to send my weekly paystubs electronically. I understand that I, or the Company, may revoke this permission in writing at any time. I further agree that in the event my email changes, I will inform the Company. This authorization will remain in effect until revoked in writing by me or the Company. Your information will be used only by the Company and will not be shared or distributed in any way.

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Job Information

What position are you applying for? Which of our office locations are you closest to? Start Date Select all available work areas: Days Available: Select available hours:
Shift Start: Shift End:

Have you applied with Anodyne before today?

Date:

Have you worked for Anodyne before today?

Start Date:

End Date:

How did you hear about Anodyne?

Employment History

Please list at least 2 current/previous positions.

Company Name: Job Title: Supervisor: Address: Telephone: Reason for leaving: Start Date: End Date: Job Duties:

Company: Title: Supervisor: Address: Telephone: Reason for leaving: Start Date: End Date: Job Duties:

May we contact all your previous employers for references?

STATEMENT OF UNDERSTANDING

Please read the following statements: they constitute the conditions under which you would be employed by Anodyne Medical Services Corp (the Company) should you be accepted for employment.

I certify that all information that I have provided on this application is true and complete to the best of my knowledge. I understand that falsification, misrepresentation or omission of facts called for in this application may result in denial of employment or immediate dismissal.

I understand that if I am employed by Anodyne Medical Services Corp (the Company), my employment is for no definite term and that I can be terminated at any time with or without notice and with or without cause. I further understand that no verbal promises, or guarantees are binding on the Company and that no one, other than the President of the Company, has authority to enter into an agreement for employment contrary to the above, and that any such agreement must be in writing. If employed, I agree to abide by all of the Company’s rules and regulations, and any changes thereto.

I understand that a job offer may be contingent upon the satisfactory results of Criminal Offender Record Information (CORI) check, Office of Inspector General (OIG) check, Department of Public Health Massachusetts Nurse Aide Registry check, Sex Offender Registry Board (SORB), Disabled Persons Protection Commission (DPPC), fingerprinting check, and receipt of medical clearance.

I give the Company permission to investigate all pertinent information concerning my application in order to determine my qualifications for employment. I understand that any offer of employment may be rescinded if the results of the investigation are unacceptable to the Company.

I hereby give my authorization for a reference check. You may release any and all information to Anodyne. I further release and hold harmless both the Company, and/or the individual providing the reference and Anodyne from any and all liability that may potentially result from the release and/or use of such information. I understand that any information released will be held in the strictest of confidence, that it will be viewed only by those involved in the hiring decision, and that neither I nor anyone else not so involved will have the right to see the information.

Massachusetts General Laws c.149 S19B requires that the following statement be included on employment applications:“It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment. An employer who violates this law shall be subject to criminal penalties and civil liability.”

Massachusetts General Laws c. 151B defines “genetic information” as any written record or explanation of a genetic test of a person’s family history with regard to the presence, absence or variation of a gene. A genetic test is broadly defined as “any test of DNA, RNA, mitochondrial DNA, chromosome or proteins for the purpose of identifying genes or genetic abnormalities.” The law expressly excludes drug and alcohol tests from this definition, meaning that employers may continue to conduct such tests in accordance with existing legal requirements.

These new statutory provisions specifically prohibit employers from (1) terminating or refusing to hire individuals on the basis of genetic information; (2) requesting genetic information concerning employees, applicants or their family members; (3) attempting to induce individuals to undergo genetic tests or otherwise disclose genetic information; (4) using genetic information in any way that affects the terms and conditions of an individual’s employment; or (5) seeking, receiving or maintaining genetic information for any non-medical purpose.