Name *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Is your mailing address the same as your physical address? *

Yes

No

Are you 18 years or older? *

Yes

No

Can you provide proof that you are legally authorized to work in the U.S.? *

Yes

No

The position may require driving, can you provide a valid driver's license and proof of insurance? *

Yes

No

I acknowledge and agree that, if engaged, my relationship with Millay House Rockland will be that of an independent contractor. I understand that I will not be an employee, agent, or representative of Millay House Rockland for any purpose. As an independent contractor, I will be responsible for my own taxes, insurance, and compliance with all applicable laws and regulations. I further acknowledge that I am not entitled to any employee benefits, including but not limited to health insurance, workers' compensation, unemployment insurance, or retirement benefits. *

I agree

I certify that my answers herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. I understand that any false, misleading, or incomplete information given during my application or subsequent interview(s) may result in denial of employment or in the termination of employment. I authorize Millay House Rockland (MHR) to check my references and to verify information contained on this application. Further, I authorize former employers (where indicated), personal references and others to give my information concerning me requested by MHR, whether or not it is in their records, and I hereby release them from any liability whatsoever. *

I agree