Employment Application

Please read each section carefully. Your submission of this application is your signature indicating that you have read and understood these waivers and disclosures. If you do not understand any information given or any of the questions asked in this application, please ask for an explanation.

It is my understanding that this employment application, or the granting of an oral interview, does not represent a contract of employment or a promise of future benefits by this organization. I understand and agree that, if hired; my employment will be at-will in nature and may be terminated, with or without cause, at any time, by either myself or my employer. I also understand that this written statement supersedes any and all oral representations made by agents or representatives of this organization.

I certify that the information in this application is true, complete, and correct. I understand that false answers, statements, or significant omissions made by me on this form shall be sufficient cause for denial of employment or discharge.

I hereby certify that, if hired, I will disclose any limitations I have that may impact my ability to do the job. I understand that I may also be required to undergo a pre-employment or post-employment medical exam by the agency’s designated health facility.

I understand that I will be subject to a background check, and hereby authorize CO-OP to investigate my background to determine any and all information of concern as to my record, whether the same is of record or not, and I release employers and persons named in my application from all liability for any damages on account of his/her furnishing said information. Additionally, you are hereby authorized to make any investigation of my personal history, educational background, military record, motor vehicle records, and criminal records through an investigative or credit agency or bureau of your choice. I authorize the release of this information by the appropriate agencies to the investigating service. This authorization, in original or copy form, shall be valid for this and for any future reports and updates that may be required. I understand that passing the background check is a condition of employment. A negative background check can be grounds for dismissal, even if an offer has been made to me and I have been hired.

I also understand that CO-OP screens potential employees to ensure that these individuals are not excluded from participation in federal healthcare programs. This screening is done through the Office of Inspector General’s List of Excluded Individuals/Entities as well as the General Services Administration’s Excluded Parties List.

Under Massachusetts Law, 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. Massachusetts General Laws c. 151B prohibits 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.

Please read each section carefully. Your submission of this application is your signature indicating that you have read and understood these waivers and disclosures. If you do not understand any information given or any of the questions asked in this application, please ask for an explanation.

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