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.

Click
here for a printable version. Applications may be mailed to the
following:
PO
BOX 35
NOTH ATTLEBORO, MA 02761
FAX 508-643-0466
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Date:
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First Name:
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Middle Initial:
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Last Name:
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Email Address:
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Daytime Phone:
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Evening Phone:
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Street:
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City:
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State:
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Zip Code:
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Years at this address?
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Previous Address:
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City:
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State:
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Zip Code:
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Years at this address?
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SSN:
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Drivers License:
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Over 18 years old?
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Height:
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Weight:
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Hair Color:
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Eye Color:
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Do you own a car?
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Year:
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Make:
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Color:
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Plate:
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Position Desired:
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Weekly Salary:
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Do you speak, read, or write any foreign languages?
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Have you served in the armed forces?
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From:
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To:
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Branch:
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Rank:
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Type of discharge:
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Have you ever been arrested?
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If yes, Why?
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Have you ever been fingerprinted?
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If yes, Why?
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Have you ever taken a polygraph?
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If yes, Why?
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Have you ever had a pistol permit?
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Where issued?
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Type:
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Expiration Date:
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Number:
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Have you ever had a private detective license revoked or denied?
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If yes, Why?
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Specify any special training or skills:
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Specify any prior investigative experience:
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Activities and Hobbies:
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Are you willing to travel?
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Distance:
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Time:
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Personal References
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List two people, not relatives or former employers |
Name:
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Occupation:
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Address:
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Phone:
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Name:
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Occupation:
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Address:
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Phone:
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Education
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Attending School Now?
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If yes, Where?
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Days/Hours:
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Studies:
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Last school attended:
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From:
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To:
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Address:
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Type:
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Graduate?
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Degree?
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Previous School:
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From:
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To:
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Address:
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Type:
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Graduate?
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Degree?
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Specify any honors, awards, or certificates received:
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Employment History
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From:
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To:
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Employer:
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Address:
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Phone:
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Position:
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Supervisor/Manager:
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Beginning Salary:
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Ending Salary:
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Description of responsibilities:
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Reason for leaving:
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From:
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To:
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Employer:
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Address:
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Phone:
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Position:
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Supervisor/Manager:
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Beginning Salary:
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Ending Salary:
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Description of responsibilities:
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Reason for leaving:
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From:
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To:
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Employer:
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Address:
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Phone:
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Position:
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Supervisor/Manager:
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Beginning Salary:
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Ending Salary:
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Description of responsibilities:
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Reason for leaving:
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Physical Record
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Name of Physician:
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Address:
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Name and Address of Hospital:
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Most recent visit to a doctor:
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Reason:
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In case of emergency, notify:
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Address:
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Phone:
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Relationship:
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State any scars, marks, or tattoos:
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Any serious illness in the last five (5) years:
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Ever file and/or be awarded a woman's compensation claim
(Explain):
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Ever receive insurance benefits as a result of a disability
(Explain):
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Check if you had or still have any of the following:
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Explain any of the above that apply:
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Release Authorization for Background Information
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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:
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Date of Birth*:
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* Date of birth is being requested for accurate retrieval of
records. |
Check
here if you accept authorization for background check above. |
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Statement of Responsibility and Liability
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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.
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Check here
if you accept the statement above. |
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Drug Free Workplace Policy
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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:
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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.
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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.
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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.
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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.
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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.
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Accent Investigations, LLC encourages any employee with a drug problem to seek
assistance from a substance abuse treatment program in his/her area.
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The law requires all employees to abide by this policy.
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Check
here if you accept the Drug Free Workplace Policy above. |
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