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Montgomery County Humane Society, Inc. (MCHS) is an equal opportunity/affirmative action employer. All qualified applicants, based upon job related qualifications, will be considered without regard to age, race, color, sex, religion, national origin, marital status, ancestry, citizenship, veteran status, sexual orientation or preference, physical or mental disability or any other classification proscribed under applicable federal, state or local law. |
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Last Name |
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First Name |
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Middle Initial |
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Maiden Name, if applicable |
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Salary Desired |
$
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Address |
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City |
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Home Phone# |
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Business/ Cell # |
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Date Available to Start work |
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Position Applying for:
Driver position requires a copy of your driving record from the DMV, prior to interview |
Full time
Part-time
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Specify days and hours
if part-time: |
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If required, would you be willing to work overtime?
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Yes
No
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Are you willing to work evening/night shift? |
Yes
No
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Do you have any allergies that would prevent you from handling the animals? |
Yes
No
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Are you afraid of handling animals?
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Yes No |
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If yes, which ones?
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Have you ever interviewed with the MCHS before?
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Yes No |
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If yes, list date(s) and position(s):
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Have you ever been employed with the MCHS before?
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Yes No |
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If yes, list date(s) and position(s):
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Do you have any relatives/friends employed by the MCHS?
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Yes No |
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If yes, list name(s) and positions:
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Are you at least 18 years old?
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Yes No |
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If under 18, do you have a work permit?
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Yes No |
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Have you ever been convicted of any violation(s) of law, including moving traffic violations?
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Yes No |
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If yes, please explain:
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EDUCATION
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Highest Grade Completed: High School
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9 10 11 12 |
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If you did not complete high school, do you have a high school equivalency diploma?
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Yes No |
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College, Trade or Business
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1 2 3 4 |
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| High School |
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NAME/LOCATION OF SCHOOL
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MAJOR STUDIES
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DEGREE, DIPLOMA, LICENSE OR CERTIFICATE
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| College/University |
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NAME/LOCATION OF SCHOOL
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MAJOR STUDIES
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DEGREE, DIPLOMA, LICENSE OR CERTIFICATE
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| Vocational, Business, Other |
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NAME/LOCATION OF SCHOOL
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MAJOR STUDIES
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DEGREE, DIPLOMA, LICENSE OR CERTIFICATE
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EMPLOYMENT HISTORY
List below your last four (4) employers, starting with the last one first. All information MUST be completed. You may attach a resume, but it does not take the place of completing all the required information. |
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Employed From
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Employed Until
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Employer’s Name
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Employer’s Address
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Supervisor’s Name
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Supervisor’s Phone #
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Starting Salary
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$ |
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Ending Salary
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$ |
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Job Title
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Duties and Responsibilities
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Reason for Leaving
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Employed From
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Employed Until
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Employer’s Name
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Employer’s Address
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Supervisor’s Name
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Supervisor’s Phone #
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Starting Salary
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$ |
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Ending Salary
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$ |
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Job Title
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Duties and Responsibilities
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Reason for Leaving
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Employed From
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Employed Until
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Employer’s Name
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Employer’s Address
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Supervisor’s Name
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Supervisor’s Phone #
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Starting Salary
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$ |
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Ending Salary
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$ |
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Job Title
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Duties and Responsibilities
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Reason for Leaving
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Employed From
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Employed Until
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Employer’s Name
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Employer’s Address
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Supervisor’s Name
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Supervisor’s Phone #
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Starting Salary
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$ |
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Ending Salary
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$ |
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Job Title
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Duties and Responsibilities
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Reason for Leaving
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May we contact your present employer?
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Yes No |
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PROFESSIONAL REFERENCES: List three (3), other than relatives
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| Relationship |
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| Phone Number |
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| Years Known |
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| Relationship |
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| Relationship |
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| Years Known |
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CERTIFICATION AND AUTHORIZATION
“I understand that that the Montgomery County Police Department (MCPD) will do a complete background check on me. I also understand that if I am employed by the Montgomery County Humane Society my employment will be terminated if MCHS is notified by the MCPD that they find my background unacceptable, i.e., arrests, convictions, drug related problems, or any other incidents that do not comply with the policies and procedures of the Montgomery County Police Department.
I certify that the facts contained in this application are true and correct. I understand that, in the event of my employment by the MCHS, I shall be subject to dismissal if any information that I have given in the application is false or misleading or if I have failed to give any information herein requested, regardless of the time elapsed after discovery.
I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information.
I understand that I shall be required to provide documentation establishing my legal authorization for employment prior to commencing work. I understand that if employed, my employment will be at will and that this is not a contract for employment or a guarantee of employment. The Employer is an Equal Opportunity Employer and shall treat all employees and applicants for employment equally and fairly based upon job related qualifications and in accordance with all applicable local, state and federal laws.
This waiver does not permit the release or use of disability-related or medical information in manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws.”
UNDER MARYLAND LAW AN EMPLOYER MAY NOT REQUIRE OR DEMAND ANY APPLICANT FOR EMPLOYMENT OR PROSPECTIVE EMPLOYMENT OR ANY EMPLOYEE TO SUBMIT TO OR TAKE A POLYGRAPH, LIE DETECTOR OR SIMILAR TEST OR EXAMINATION AS A CONDITION OF EMPLOYMENT OR CONTINUED EMPLOYMENT. ANY EMPLOYER WHO VIOLATES THIS PROVISION IS GUILTY OF A MISDEMEANOR AND SUBJECT TO A FIND NOT TO EXCEED $100.
I understand that the position I am applying for may/will require me to:
· Lift between 15 - 60 lbs.
· Restrain a 65 lb. animal
· Stand for long periods of time
· Pass a police background check
· Receive 3 pre-exposure rabies vaccines shots
· Handle vicious and dangerous animals |
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Applicant’s Name
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Date
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