Town of West Springfield

Employment Application
The Town of West Springfield is an
Affirmative Action / Equal Employment Opportunity Employer

Personal Information
10/08/13
1. Date of Application: _____________________
3. Are you available to work:

Full time

2.

Dispatcher
Position Applying For: _________________________

Part time

If part time, what will be your days/hours of availability?

______________________________________________

Nascimento
Jamie
4. Name: ____________________________________________________________________________________
Last
First
Middle
665 Prospect Avenue
5. Address: ___________________________________________________________________________________
Number
Street
Apartment Number
West Springfield
MA
01089
___________________________________________________________________________________
City/Town
State
Zip Code
413-788-7257
413-626-3346
6. Telephone Number: Home: _____________________________
Daytime: ______________________________
Area Code/Number
Area Code/Number
024-60-7927
S91045611
7. Social Security Number: _____________________
8. Drivers License Number: _____________________
Class/Number/State
9. If hired, can you provide proof of citizenship or legal right to work?
10. Are you under 18, can you furnish a work permit?
11. Have you ever been employed by the Town before?
If yes, when? ____________________

Yes

Yes

No

No

No
Yes
In which department? ________________________

12. Do you have an immediate family member (i.e. spouse, mother, father, sibling, or child) working for the Town?
No
Yes
If yes, Employees Name: ___________________________ Department: ___________________________

Education
Name/Location

Major

Graduated

Yes

or

Degree Received

No

High School
College

Westfield State College Movement Science

Graduate School
Business/Technical

Yes

Bachelors of Science

Employment History
List present employer first. A resume or supplement sheet may be included, however, this section must be completed.
Planet Fitness
13. Employers Name: _______________________________________
413-731-7555
1464 Riverdale Street, West Springfield, MA
Address: __________________________________________________
Telephone Number: ___________
Fitness Instructor
04/09
05/11
Job Title: _______________________________________
Worked From: __________
To: _________

Mike Shea, Facility Manager

Immediate Supervisors Name and Job Title: ________________________________________________________
$9/hr.
$13/hr
Yes
Salary: _______________/_________________
May we contact this employer?
No
Starting
Ending
instructing members on theory of exercise, how to properly use the fitness
Describe the work you performed: _________________________________________________________________

equipment, how to construct an exercise program, and general fitness knowledge-base.

_____________________________________________________________________________________________
Change in Management and personel
Reason(s) for leaving: ___________________________________________________________________________
14. Employers Name: _______________________________________
Address: __________________________________________________
Job Title: _______________________________________

Telephone Number: ___________

Worked From: __________ To: _________

Immediate Supervisors Name and Job Title: ________________________________________________________

Salary: _______________/_________________
Starting
Ending

May we contact this employer?

Yes

No

Describe the work you performed: _________________________________________________________________

_____________________________________________________________________________________________
Reason(s) for leaving: ___________________________________________________________________________
15. Employers Name: _______________________________________
Address: __________________________________________________
Job Title: _______________________________________

Telephone Number: ___________

Worked From: __________ To: _________

Immediate Supervisors Name and Job Title: ________________________________________________________

Salary: _______________/_________________
Starting
Ending

May we contact this employer?

Yes

No

Describe the work you performed: _________________________________________________________________

_____________________________________________________________________________________________
Reason(s) for leaving: ___________________________________________________________________________
16. Employers Name: _______________________________________
Address: __________________________________________________
Job Title: _______________________________________

Telephone Number: ___________

Worked From: __________ To: _________

Immediate Supervisors Name and Job Title: ________________________________________________________

Salary: _______________/_________________
Starting
Ending

May we contact this employer?

Yes

No

Describe the work you performed: _________________________________________________________________

_____________________________________________________________________________________________
Reason(s) for leaving: ___________________________________________________________________________

17. Do you possess the following skills? Please list in detail all that apply.
Specialized Training?
Yes
No
Yes
Professional Licenses?
No
Professional Memberships? Yes
No

Computer Software?
Yes
No
Yes
Office Equipment?
No
Additional Skills or More Detailed Information:

Name of Training/Course: ____________________________

1st Aid/CPR/AED
Licenses: _________________________________________
Name of Organizations: _____________________________
Microsoft Office, Internet/Web Browser
Name of Programs: _________________________________
Fax, PC, Phone
Describe Equipment: ________________________________

I've been a Certified Personal Trainer - NSCA,AFAA - since 2008.

References
Please provide professional and/or business references only. Note that references listed in this section may be contacted.
18. Reference #1

70 N. Westfield St., Feeding hills, MA

Susan Guidi
Name: ___________________________________
Address: _________________________________________
413-786-6611
D.O.R. - City of Springfield Telephone
Business position: __________________________
Home: ______________________________
Work: ______________________________
19. Reference #2

Mike Shea
335 Russell St., Hadley, MA
Name: ___________________________________
Address: _________________________________________
Facility Manager, Planet Fitness Telephone
Business position: __________________________
Home: ______________________________
413-582-9900
Work: ______________________________
20. Reference #3

303 Homestead Ave, Holyoke, MA

Johanna Brown
Name: ___________________________________
Address: _________________________________________
Director of Alumni Relations, HCC Telephone
Business position: __________________________

Home: ______________________________
413-522-2253
Work: ______________________________

21. Reference #4

Dr. Holly Noun

577 Western Ave., Westfield, MA
Name: ___________________________________
Address: _________________________________________
Dept. Chair, Mvmt. Sci., Westfield State Telephone
Business position: __________________________

Home: ______________________________
413-572-5364
Work: ______________________________

22. How did you learn about the job for which you are applying for?
Walk-in

Town Employees

Newspaper; title __________________________

Professional Journal; title ____________________

Posted Town Bulletin _____________________

MassLive.com
The Internet ______________________________

Other _______________________________________________________________________________

Agreement
The information provided in this application for employment is true and complete to the best of my knowledge. In
the event of employment, I understand that false or misleading information given in my application or interview(s)
may result in discharge.
I authorize investigation of all statements contained in this application and the release of any pertinent
information regarding my education, past employment history and background. I authorize the Town of West
Springfield to obtain any information from schools, employers or individuals relating to my activities. This
information may include, but is not limited to: academics, achievement, performance, attendance, personal history
and discipline. Further, I hereby authorize all references, persons, schools, my current employer (if applicable) and
previous employers and organizations named in this application, unless otherwise stated, to provide the Town of
West Springfield any relevant information that may be required to arrive at an employment decision. I
understand that the information released is for the Town of West Springfields use only.
I hereby voluntarily release, discharge and exonerate the Town of West Springfield, its agents and
representatives, and any person so furnishing information from any and all liabilities of every nature and kind
arising out of the furnishing or inspection of such documents, records and other information or the investigations
made by or on behalf of the Town of West Springfield.
I understand that all appointments are probationary and that I must demonstrate my ability for continued
employment. I also understand that I must be available from time to time to work outside normal business hours,
as the needs of the department require.
If required for the position I am seeking, I agree to take a physical examination, which may include testing for
drugs or a psychological examination, as required, and recognize that any offer or employment may be contingent
upon the results of such an examination.
I understand that any employment offer by the Town is conditional upon my ability to establish employment
eligibility under the Immigration Reform and Control Act of 1986 within three days of the date of hire.
I represent that I have read and fully understand the foregoing and seek employment under these
conditions. By typing my name in the Signature box, I certify the information provided as true and that
this information can be used for the purpose of processing my employment application.

Jamie Nascimento

Signature of Applicant: ____________________________________

Type Your Name

10/8/13

Date: ___________________________

Discrimination against any person in any practice or procedure in advertising, recruitment, referrals,
testing, hiring, transfer, promotion or any other term, condition or privilege of employment which limits
or adversely affects employment opportunities, because of political or religious opinions or affiliations, or
because of race, color, sex, sexual orientation, national origin, marital status, pregnancy, parenthood, age
or handicap which is unrelated to the persons occupational qualifications or any other non-merit factor
which is not a bona fide occupational qualification is prohibited.
It is unlawful in Massachusetts to require a lie detector test as a condition of employment or continued
employment. An employer who violates that law shall be subject to criminal penalties and civil liabilities.

Town of West Springfield

EQUAL EMPLOYMENT OPPORTUNITY INFORMATION REQUEST
In accordance with Town of West Springfield affirmative action policies, we request your
VOLUNTARY completion of this questionnaire. The questionnaire will be used ONLY for the
purpose of monitoring the success of our affirmative action program. In no way will the
information be used to discriminate against or to show preference for any applicant in the hiring
decision.
NOTE: Please return this form as soon as possible to: Town of West Springfield, Human Resources Dept
26 Central Street, West Springfield, MA 01089

Jamie Nascimento
10/8/13
NAME: ________________________________________
DATE: ________________________
Dispatcher
POSITION APPLIED FOR: ______________________________________________________
Information on this position was made available to me from the following source:
MassLive.com
Examples: (Name specific newspaper, journal, person, etc.) _____________________________
CITIZENSHIP:

U.S.______

OTHER (country) __________________________________

Ethnic Data:
The categories below should not be interpreted as scientific or anthropological in nature. They
were developed by the federal government to provide for the collection and use of compatible
and exchangeable ethnic data.
______

American Indian or Alaskan Native (a person having origins in any of the original people of
North America and who maintains cultural identification through tribal affiliation or community
recognition.)

_______

African American (a person who is not Hispanic in origin but having origins in any of the original
peoples of Central or South Africa.)

_______

Asian or Pacific Islander (a person having origins in any of the original peoples of the Far East,
Southeast Asia, and the Indian sub-continent of the Pacific Isles.)

______

Hispanic (a person of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish
culture regardless of race.)

_______

White (a person who is not of Hispanic origin but having origins in any of the original peoples of
Europe, North Africa, or the Middle East.)

_______

Cape Verdean (a person not of Hispanic origin but having origins in the peoples of the Cape
Verde Islands.)

SEX: _________Female_________Male

03/31/1980

DATE OF BIRTH: __________________________________

Specify any physical or mental handicap which may require consideration in your employment
for the Town of West Springfield:
______________________________________________________________________________
______________________________________________________________________________

Are you a Veteran? ______Yes ______No If yes, dates of service________________________

CORI REQUEST FORM

The Town of West Springfield has been certified by the Criminal History Systems Board for access to
the Town of West Springfield
conviction and pending criminal case data. As an applicant/employee for_________________________,
I understand that a criminal record check will be conducted for conviction and pending criminal case
information only and that will not necessarily disqualify me. The information below is correct to the best
of my knowledge.

Nascimento
Last Name

Jamie
First Name

Middle Name

Suffix

Maiden Name (or other name(s) by which you have been known

03/31/1980
______________________________
Date of Birth

Holyoke, MA
__________________________________________________
Place of Birth

607927
Last Six Digits of Your Social Security Number: _____________________________________________
M Height: ______feet
5
9
Sex:______
_______inches

Brown Race:_________________
White
Eye Color:___________

S91045611
MA
Drivers License or ID Number:___________________________
State of Issue:____________________
Judite Muche Fathers Full Name:____________________
Mothers Full Maiden Name:________________________
Antonio Nascimento

Current and Former Addresses:

665 Prospect Avenue

West Springfield

Street Number and Name

City/Town

212 Beech Street

Holyoke

Street Number and Name

City/Town

MA
State

MA
State

01089
Zip

01040
Zip

The above information was verified by reviewing the following form(s) of government-issued
identifications:

VERIFIED BY:
_____________________________________________________________________________________
Name of Verifying Employee (Please Print)

Signature of Verifying Employee