IMPORTANT: Please read these instructions carefully. So that we may more quickly evaluate and process your application for employment, please be sure to complete all sections of this application. Even if you have submitted a resume, you should complete this document in its entirety as the requested information may not be contained on your resume. DO NOT write “See Resume” in ANY section of this document. Incomplete applications will not be processed.





Work Availability:


I am available:


How did you hear about the position? Please, be specific.


Have you ever worked for Minute Man Arc before?

if yes:


Is anyone related to you presently employed by Minute Man Arc?

if yes:


If you are under 18 years old, can you furnish a work permit?


Are you legally eligible to work in the United States?

(Proof of U.S. Citizenship or immigration status will be required upon employment.)


Please be sure to list ALL positions held by you for at least the last seven years. Start with the employment you currently have, or most recently had, and work back in time from there. You can also include work performed as a volunteer and any prior or current military service.


Current/Most Recent Employer

Can we contact this employer about your employment there?


Previous Employer

Can we contact this employer about your employment there?


Previous Employer

Can we contact this employer about your employment there?


Previous Employer

Can we contact this employer about your employment there?


Did you graduate?


Did you graduate?


Did you graduate?


Did you graduate?


License or Certification?


Skill, Additional Experience or Qualifications

List any other experience or job related skills, activities or qualifications (e.g. foreign languages, computers, community, social and professional organizations CPR, First Aid, MAP etc.) which you believe should be considered in evaluating your qualifications for employment.


List the names and telephone numbers of at least three (3) previous supervisors/managers/teachers/co-workers who are NOT related to you. Do not include the names of friends.



NOTIFICATION AND AGREEMENT (Please read before signing):

I certify that all information given by me as part of the application process is true, accurate and complete and I have withheld nothing that would, if disclosed, affect the application unfavorably. I understand that falsification, misrepresentation, or omission of fact on this application (or any accompanying or required documents) will be cause for denial of employment or immediate termination of employment, regardless of when or how discovered.

This application will be given every consideration but its receipt does not imply that I will be employed. If hired, I will comply with all company rules and regulations. I understand that the hiring process involves submission and review of this application and an interview. I understand that any job offer may be contingent upon a satisfactory driving, background, and reference check.

If I am offered employment, I understand that my employment is for no stated term and is considered at-will, and may be terminated by MMA or me with or without cause or notice at any time. Also I understand that this application is not intended to be a contract of employment, nor does it impose any obligation upon MMA if they decide to hire me.

I hereby authorize previous employers, references, and educational institutions listed above to provide MMA with any information concerning my employment, work performance personal character, and any other information that may be pertinent to my qualification for employment. Furthermore I release all parties from liability for any damage that may result in the furnishing of such information. In processing this application, MMA may request that an investigative consumer report be prepared which may include information about my character, general reputation, employment history, education, credit record and any criminal convictions. I have the right to request, in writing, upon receipt of notice that such an investigation was conducted, a complete and accurate written disclosure of the nature and scope of the investigation.

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.

MMA is an Equal Opportunity Employer and does not discriminate on the basis of race, age, religion, national origin, color, gender, creed, ancestry, marital status, sexual orientation, pregnancy, or veteran status. All applicants will be given equal opportunity and selected based on job related skills. A qualified individual with a qualified disability under the ADA will not be refused based on the need of a reasonable accommodation.



Minute Man Arc is an Equal Opportunity Employer/Disabled/VETS/Affirmative Action Employer. As required by law, we must record certain information to be made a part of our Affirmative Action Program. As part of our continuing commitment to Equal Employment Opportunity, Minute Man Arc for Human Services has a policy of hiring and promoting individuals based on ability and potential and without regard to those facts that have no bearing on the execution of job responsibilities. The agency takes affirmative action steps to employ and advance females, minorities, individuals with disabilities and protected veterans. To enable us to meet government reporting requirements, we request that you complete this personal data form. Any information that you choose to provide will not be considered by us for employment purposes and will be treated as personal and confidential. Provision of this information is VOLUNTARY and refusal to provide it will not subject you to any adverse treatment and will have no bearing on your application. This information will be kept in a CONFIDENTIAL file, separate from other hiring credentials. It will only be used in accordance with applicable laws and regulations. Your cooperation is appreciated.








Minute Man Arc is a government contractor subject to the Vietnam Era Veterans’ Readjustment Assistance Act of 1974 (VEVRAA). Minute Man Arc is required to take affirmative action to employ and advance in employment disabled veterans, recently separated veterans, active duty wartime or campaign badge veterans and Armed forces service medal veterans. If you are a disabled veteran it would assist us if you tell us whether there are accommodations we could make that would enable you to perform the essential functions of the job. This information will assist us in making reasonable accommodations for your disability. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information provided will be used only in ways that are not inconsistent with VEVRAA as amended.

Your cooperation is appreciated

A “Disabled Veteran” is a veteran of the U.S. military who (i) is entitled to compensation (or who but for the receipt of military pay would be entitled to compensation) under laws administered by the Secretary of Veteran Affairs, or (ii) was discharged or released from active duty because of a service-connected disability.

A “Recently Separated Veteran” means a veteran who served on active duty in the U.S. military, ground, naval or air service hired during the three-year period beginning on the date of your discharge or release from active duty.

An “Active Duty Wartime or Campaign Badge Veteran“ means a veteran who served on active duty in the U.S. military, ground, naval or air service during a war or in a campaign or expedition for which a campaign badge has been authorized. Information to identify the campaigns or expeditions that meet this criterion is available at A copy of the list may also be obtained by calling (301) 306-6752 and requesting that a copy of the list be mailed to you.

An “Armed Forces Service Medal Veteran” means any veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985 (61FR 1209).

If you believe you belong to any of the categories of protected veterans listed above, please indicate by checking the appropriate box below. As a Government contractor subject to VEVRAA, we request the information in order to measure the effectiveness of the outreach and positive recruitment efforts we undertake pursuant to VEVRAA.



The information you submit will be kept confidential, except that supervisors and managers may be informed regarding restrictions on the work or duties of disabled veterans, and regarding necessary accommodations; first aid and safety personnel may be informed, when and to the extent appropriate., if you have a condition that might require emergency treatment; and Government officials engaged in enforcing laws administered by the Office of Federal Contract Compliance Programs or enforcing the Americans with Disabilities Act may be informed.



Why are you being asked to complete this form?

Because we do business with the government, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities.i To help us measure how well we are doing, we are asking you to tell us if you have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will choose to fill it out. If you are applying for a job, any answer you give will be kept private and will not be used against you in any way.

If you already work for us, your answer will not be used against you in any way. Because a person may become disabled at any time, we are required to ask all of our employees to update their information every five years. You may voluntarily self-identify as having a disability on this form without fear of any punishment because you did not identify as having a disability earlier.


How do I know if I have a disability?

You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition.

Disabilities include, but are not limited to:


  • Blindness
  • Autism
  • Bipolar disorder
  • Post-traumatic stress disorder (PTSD)
  • Deafness
  • Cerebral palsy
  • Major depression
  • Obsessive compulsive disorder
  • Cancer
  • Multiple sclerosis (MS)
  • Impairments requiring the use of a wheelchair
  • Diabetes
  • Epilepsy
  • Schizophrenia
  • Muscular dystrophy
  • Missing limbs or partially missing limbs
  • Intellectual disability (previously called mental retardation)




How do I know if I have a disability?

Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of reasonable accommodation include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment.

Section 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal employment obligations of Federal contractors, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at

PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. This survey should take about 5 minutes to complete.


Check all of the shift for which you are available

Weekday 2nd Shift (40 hours: 38 Direct Care + 1 hour staff meeting and 1 hour individual supervision during weekday hours)



Quadruple Overnight Shift (40 hours: 38 Direct Care + 1 hour staff meeting and 1 hour individual supervision during weekday hours)



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