Employment Application

General Information

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Education Information

Employment History

From: To:
From: To:
From: To:

Please read the following statements. They constitute the conditions under which you would be employed by our
Company, should you be accepted for employment.

I certify that all information that I have provided on this application is true and complete to the best of my knowledge. I
understand that falsification, misrepresentations or omission of facts called for in this application may result in denial of
employment or immediate dismissal.

I understand that if I am employed by the Company, my employment is for no definite term and that I can be terminated at any
time with or without notice and with or without cause. I further understand that no verbal promises or guarantees are binding
on the Company and that no one, other than the President of the Company, has authority to enter into an agreement for
employment contrary to the above and that any such agreement must be in writing. If employed, I agree to abide by all of the
Company’s rules and regulations and any changes thereto.

I understand that a job offer may be contingent upon the satisfactory results of a physical examination and/or drug screening.
(Note: You will be notified if these are a requirement and all related expenses are paid by the company.)

I give the Company permission to investigate all pertinent information concerning my application in order to determine my
qualifications for employment. I understand that any offer of employment may be rescinded if the results of the investigation
are unacceptable to the Company.

Please check to accept:

Massachusetts General Laws c.149 s19B requires that the following statement be included on employment applications: “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 defines “genetic information” as any written record or explanation of a genetic test of a person’s
family history with regard to the presence, absence or variation of a gene. A genetic test is broadly defined as “any test of DNA, RNA,
mitochondrial DNA , chromosome or proteins for the purpose of identifying genes or genetic abnormalities.” The law expressly
excludes drug and alcohol tests from this definition, meaning that employers may continue to conduct such tests in accordance with
existing legal requirements.

These new statutory provisions specifically prohibit 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 the individual’s employment; or (5) seeking, receiving or maintaining genetic information for any
non-medical purpose.