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MASSACHUSETTS GENERAL LAWS c. 149. § 19B requires the following statement: 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.

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Click here for a printable version. Applications may be mailed to the following:

PO BOX 35
NOTH ATTLEBORO, MA 02761 
FAX 508-643-0466


Date:
First Name:
Middle Initial:
Last Name:
Email Address:
Daytime Phone:
Evening Phone:
Street:
City:
State:
Zip Code:
Years at this address?
Previous Address:
City:
State:
Zip Code:
Years at this address?
SSN:
Drivers License:
Over 18 years old?
Height:
Weight:
Hair Color:
Eye Color:
Do you own a car?
Year:
Make:
Color:
Plate:
Position Desired:
Weekly Salary:
Do you speak, read, or write any foreign languages?
Have you served in the armed forces?
From:
To:
Branch:
Rank:
Type of discharge:
Have you ever been arrested?
If yes, Why?
Have you ever been fingerprinted?
If yes, Why?
Have you ever taken a polygraph?
If yes, Why?
Have you ever had a pistol permit?
Where issued?
Type:
Expiration Date:
Number:
Have you ever had a private detective license revoked or denied?
If yes, Why?
Specify any special training or skills:
Specify any prior investigative experience:
Activities and Hobbies:
Are you willing to travel?
Distance:
Time:

Personal References

List two people, not relatives or former employers
Name:
Occupation:
Address:
Phone:
Name:
Occupation:
Address:
Phone:

Education

Attending School Now?
If yes, Where?
Days/Hours:
Studies:
Last school attended:
From:
To:
Address:
Type:
Graduate?
Degree?
Previous School:
From:
To:
Address:
Type:
Graduate?
Degree?
Specify any honors, awards, or certificates received:

Employment History

From:
To:
Employer:
Address:
Phone:
Position:
Supervisor/Manager:
Beginning Salary:
Ending Salary:
Description of responsibilities:
Reason for leaving:
From:
To:
Employer:
Address:
Phone:
Position:
Supervisor/Manager:
Beginning Salary:
Ending Salary:
Description of responsibilities:
Reason for leaving:
From:
To:
Employer:
Address:
Phone:
Position:
Supervisor/Manager:
Beginning Salary:
Ending Salary:
Description of responsibilities:
Reason for leaving:

Physical Record

Name of Physician:
Address:
Name and Address of Hospital:
Most recent visit to a doctor:
Reason:
In case of emergency, notify:
Address:
Phone:
Relationship:
State any scars, marks, or tattoos:
Any serious illness in the last five (5) years:
Ever file and/or be awarded a woman's compensation claim (Explain):
Ever receive insurance benefits as a result of a disability (Explain):
Check if you had or still have any of the following:
Broken Bones Hernia or Rupture heart Disease
High Blood Pres. Defective Eyesight Strains
Dislocations Kidney Trouble Dizziness
Hearing Impair Amputations Stiff Joints
Tuberculosis Nervous Disorders Skin Disease
Cancer/Tumer Venereal Disease Concussion
Skull Fracture Circulatory Disease Diabetes
Phys. Deformity Back Trouble Epilepsy
Any Disability Lung Condition Panting
Explain any of the above that apply:

Release Authorization for Background Information

IN CONNECTION WITH, AND DURATION OF MY EMPLOYMENT (INCLUDING CONTRACT FOR SERVICES) WITH YOU, I UNDERSTAND THAT INVESTIGATIVE BACKGROUND INQUIRIES ARE TO BE MADE ON MYSELF INCLUDING CONSUMER, CRIMINAL, DRIVING AND OTHER REPORTS. THESE REPORTS WILL INCLUDE INFORMATION AS TO MY CHARACTER, WORK HABITS, PERFORMANCE AND EXPERIENCE ALONG WITH REASONS FOR TERMINATION OF PAST EMPLOYMENT FROM PREVIOUS EMPLOYERS. FURTHER, I UNDERSTAND THAT YOU WILL BE REQUESTING INFORMATION FROM VARIOUS FEDERAL, STATE AND OTHER AGENCIES WHICH MAINTAIN RECORDS CONCERNING MY PAST ACTIVITIES RELATING TO MY DRIVING, CREIT, CRIMINAL, CIVIL AND OTHER EXPERIENCES AS WELL AS CLAIMS INVOLVING ME IN THE FILES OF INSURANCE COMPANIES.

I AUTHORIZE, WITHOUT RESERVATION, ANY PARTY OR AGENCY CONTACTED BY THIS EMPLOYER TO FURNISH THE ABOVE-MENTIONED INFORMATION:
Date of Birth*:
* Date of birth is being requested for accurate retrieval of records.
Check here if you accept authorization for background check above.

Statement of Responsibility and Liability

I,
, RECOGNIZE THAT IN MY CAPACITY AS AN EMPLOYEE OF ?CCENT INVESTIGATIONS I WILL BE RESPONSIBLE TO MAKE ACCURATE REPORT ENTRIES, WHICH MUST BE HONESTLY SET FORTH AND ACCURATE TO THE BEST OF MY ABILITY.

I FURTHER RECOGNIZE THAT ALL INFORMATION PERTAINING TO ?CCENT INVESTIGATIONS’ (?CCENT) CLIENTS IS HIGHLY CONFIDENTIAL AND I AGREE TO PROTECT SAID CONFIDENTIALITY OF CLIENT NAMES, JOB SITE LOCATIONS, JOB RELATED INCIDENTS, ETC. I FURTHER RECOGNIZE THAT FAILURE TO PROTECT SAID CONFIDENTIALITY, OR KNOWINGLY GIVE FALSE INFORMATION ON MY REPORTS MAY COMPROMISE MYSELF, THE CLIENT, OR ?CCENT, AND I RECOGNIZE THAT ANY SUCH ACTIONS ON MY PART, MAY RESULT IN MY IMMEDIATE TERMINATION, AND MY ASSUMING LIABILITY, EITHER CIVIL OR CRIMINAL, INCLUDING MONETARY DAMAGES, AND I HEREBY INDEMNIFY ?CCENT AGAINST SUCH ACTIONS. IN ACCEPTING EMPLOYMENT WITH ?CCENT, I AGREE TO ABIDE BY RULES AND REGULATIONS, WHICH ARE IN EFFECT, OR MAY BE ESTABLISHED IN THE FUTURE.

I DECLARE THAT MY ANSWERS TO THE QUESTIONS ON MY APPLICATION ARE TRUE AND CORRECT, AND GIVE ?CCENT THE RIGHT TO INVESTIGATE ANY AND ALL REFERENCES GIVEN, AND TO SECURE ADDITIONAL INFORMATION RELATING TO THE APPLICATION. I HEREBY RELEASE FROM ALL LIABILITY OR RESPONSIBILITY, ALL PERSONS, COMPANIES, OR CORPORATIONS FURNISHING INFORMATION ABOUT ME IN CONNECTION WITH MY APPLICATION FOR EMPLOYMENT.
Check here if you accept the statement above.

Drug Free Workplace Policy

Drug use and abuse at the workplace or while on duty are subjects of immediate concern in our society. These problems are extremely complex and ones for which there are no easy solutions. From a safety perspective, the users of drugs may impair the well being of all employees, the public at large. And result in damage to property.Therefore, it is the policy of ?ccent Investigations, LLC, that the unlawful manufacture, distribution, dispensation, possession or use of a controlled substance is prohibited in the workplace. Any employee(s) violating this policy will be subject to discipline up to and including termination. An employee may also be discharged or otherwise disciplined for a conviction involving illicit drug behavior, regardless of whether his/her actions were connected in any way with his or her employment. The specifics of this policy are as follows:
  1. Any unauthorized employee who gives or in any way transfers a controlled substance to another person or sells or manufactures a controlled substance while on duty, regardless of whether the employee is on or off the premises of the employer will be subject to discipline up to and including termination.
  2. The term “controlled substance” means any drugs listed in 21 U.S.C. 812 and other federal regulations. Generally, all illegal drugs and substances are included, such as marijuana, heroin, morphine, cocaine, codeine, or opium additives, LSD, DMT, STP, amphetamines, methamphetamines, and barbituates.
  3. Each employee is required by law to inform the agency within five (5) days after he/she is convicted for violation of any federal or state criminal drug statute. A conviction means a finding of guilt (including a plea of nolo contendre) or the imposition of a sentence by a judge or jury in any federal or state court.
  4. The employer (the hiring authority) will be responsible for reporting conviction(s) to the appropriate federal granting source, within (10) days after receiving notice from the employer or otherwise receives actual notice of such conviction(s).All conviction(s) must be reported in writing to the Office of Personnel Administration (OPA) within the same time frame.
  5. If an employee is convicted of violating any criminal drug statute while on duty, he/she will be subject to discipline up to and including termination. Conviction(s) while off duty may result in discipline or discharge.
  6. Accent Investigations, LLC encourages any employee with a drug problem to seek assistance from a substance abuse treatment program in his/her area.
  7. The law requires all employees to abide by this policy.
Check here if you accept the Drug Free Workplace Policy above.

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