Application For Employment

The Martin Pollak Project, Inc. is an equal opportunity employer and in conformity with applicable laws does not
discriminate on the basis of race, color, religion, age, sex, national origin, marital status, veteran status, physical
or mental handicap, personal appearance, family responsibilities, matriculation, political affiliation and any other
impermissible criteria according to applicable law. No question on this application is intended to secure such
information to be used for such discrimination. This application will be given every consideration but its receipt
does not imply that the applicant will be employed. This application is valid for only thirty (30) days. For
consideration of employment opportunities after thirty (30) days, you must reapply.

    GENERAL INFORMATION












    Have you ever been employed at The Martin Pollak Project, Inc?



    If so, please provide dates and location(s) of employment:


    Have you previously applied for employment with The Martin Pollak Project, Inc.?



    If so, please provide month and year of previous application(s):


    How did you learn about potential employment with The Martin Pollak Project, Inc.?


    Minimum acceptable rate of pay:


    OR



    Date available for work if employment offer is extended:



    Indicate whether you have interest in: (Check all that interest you)


    Are you available for weekend and evening work?


    Please answer the following questions honestly and to the best of your knowledge:


    If hired, are you able to show proof of attaining at least 18 years of age?



    If hired, are you able to show proof of eligibility to work in the U.S.?



    If hired, it is an essential function of MPP positions which work with youth to always
    possess a current, valid drivers’ license. Do you understand this requirement?



    Do you possess a current, valid drivers’ license?




    If no, do you have reason to suspect you cannot obtain a current, valid drivers’ license in
    this State?



    If yes, please describe:


    It is a requirement of all positions which work directly with the youth that you must have
    access to (i.e., own, lease, rent, or otherwise have access to) a vehicle at all times in the
    event you are required to provide services to the youth population in your care. Do you
    understand this requirement?



    Do you have access to a vehicle at all times?



    Do you have any relatives, by marriage or blood, who are now employed by MPP?



    Have you ever been convicted of a felony or misdemeanor? (Answering “yes” to this
    question does not automatically exclude you from employment consideration.)



    If yes, please describe:

    EDUCATION AND EMPLOYMENT RECORD


    Please attach resume, educational transcript, training certificates and, where applicable, copies of professional licenses or certifications.


    Highest level of education attained:











    Number of credit hours completed as of today:











    Other education, training, licenses, etc. relevant to considering your application for the position you are seeking:


    Membership in and/or contributions to any association or organization you wish to have considered in your application:

    EMPLOYMENT HISTORY


    Please list each of your previous employers in the previous 10 years, beginning with your MOST RECENT EMPLOYER, and working back chronologically. All information must be supplied on this form, even if you attach a resume.

    Employer's Address and Telephone Number

    Immediate Supervisor's Name

    Dates of Employment

    Starting & Ending Rates of Pay

    Reason for Leaving


    You may contact the employers listed above unless I indicate those I do not want you to contact. Do not contact the following employer(s) for the following reason(s):


    Have you ever been involuntarily discharged from employment?



    If yes, please describe:

    EMPLOYMENT REFERENCES


    Please list at least three (3) personal and professional references (persons who are not related to you). Do not include employers or supervisors listed on previous page.









    AUTHORIZATION


    I hereby affirm that the facts contained in this application are true, correct and complete to the best of my knowledge. I have not withheld any factor or circumstance which would, if discovered, affect my application unfavorably. I understand that the misrepresentation or omission of a fact called for in this application or other company records may be cause for immediate dismissal.

    I further authorize MPP or its agents to verify any and all information contained herein. This includes the investigation of references and employers listed within to provide you any and all information concerning my previous employment and other pertinent information.

    I hereby authorize and permit MPP or its agents to hereafter investigate and disclose information contained in this application and such additional information regarding my employment with MPP to any person, firm or organization (e.g, FBI or State Police re: criminal check). I also release the Company and its agents from all liability for any damage that may result from utilization of such information.

    I also understand and agree that no representative of the Company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing unless it is written and signed by an authorized company representative. I also understand if I should become employed by the Company that my employment would be at-will and could be terminated by me or the Company at any time without cause and without notice.

    I hereby acknowledge that I have read all of the above Statements and understand the same.

    Under the Federal Employee Polygraph Act of 1988, and under many State-equivalent acts, an employer may not require 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 act may have court actions brought against them by the Secretary of Labor to restrain any such violation and assess civil money penalties up to $10,000.