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CAREERS

Are you passionate about providing care and assistance to those who are in need? Join our team by filling out the form below.

*REQUIRED INFORMATION

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

Enter number of hours here

POSITION APPLYING FOR

First Name

Last Name

State

Address

Postal code

City

WORK PHONE NUMBER

HOME 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

Full 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

END DATE

POSITION

REASON FOR LEAVING

Education

HIGH SCHOOL

HIGH SCHOOL LOCATION

YEARS COMPLETED

DATE GRADUATED

COLLEGE

COLLEGE LOCATION

YEARS COMPLETED COLLEGE

DATE GRADUATED IN COLLEGE

OTHER

LOCATION(OTHER)

YEARS COMPLETED(OTHER)

DATE GRADUATED(OTHER)

HIGHEST RANK ACHIEVED

CURRENTLY IN A RESERVE UNIT?

YES

NO

SPECIAL SCHOOLING OR DUTIES

LICENSE AND CERTIFICATIONS

LICENSE OR CERTIFICATIONS

ID NUMBER

EXPIRATION DATE

STATE(LICENSE)

CRIMINAL HISTORY

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

YES

NO

EMPLOYEE CANDIDATE NAME

DATE(CRIMINAL HISTORY)

REFERENCE FORM

COMPANY NAME

ADDRESS(REFERENCE FORM)

PHONE(REFERENCE FORM)

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

LAST NAME(INDIVIDUAL APPLIED)

FIRST NAME(INDIVIDUAL APPLIED)

MIDDLE NAME(INDIVIDUAL APPLIED)

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(APPLICATION)

THIS SECTION TO BE COMPLETED BY PERSON COMPLETING THIS FORM

Employment Dates:

FROM

TO

POSITION(EMPLOYMENT)

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

CONTACT US

Get In Touch

Contact Details

978.710.9302 | Fax: 978.616.7210 Email:
admin@mer-institute.com
92 Middlesex St Tyngsborough MA

92 Middlesex Rd, Tyngsborough, MA 01879, USA

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Phone 978.710.9302 | Fax: 978.616.7210
admin@mer-institute.com

92 Middlesex St

Tyngsborough MA

92 Middlesex Rd, Tyngsborough, MA 01879, USA

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