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Personal Data Last Name:* First Name:* Middle Initial: Home Address:* Apt. #: City / Town:* State:* AL AK AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY   Zip / Country Code:* Home Phone:* E-Mail:*   Work Phone: Mobile Phone:   Please list your previous addresses for the past five years: Home Address: Apt. #: City / Town: State: AL AK AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY   Zip / Country Code: Home Address: Apt. #: City / Town: State: AL AK AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY   Zip / Country Code: Home Address: Apt. #: City / Town: State: AL AK AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY   Zip / Country Code:

Employment Information I understand that an offer of employment and continued employment with Mid Cape Home Centers are contingent upon satisfactory proof of authorization to work in the United States. I Understand* Desired Salary Range*   Employment Availability (Please specify day & month) Can begin work on:*   How were you referred to Mid Cape Home Centers?   Have you ever applied for a position with Mid Cape Home Centers?*   Yes    No If yes, when? Were you interviewed?*   Yes    No If yes, by whom? Are you able to work the following?* Note: unavailability to work certain times may, but will not necessarily, be a bar to employment. Overtime:    Yes    No Evenings:    Yes    No Weekends:    Yes    No 2nd Shift:    Yes    No 3rd Shift:    Yes    No Holidays:    Yes    No Have you ever been convicted of a crime?*   Yes    No If yes, describe? Within the past five years, have you been convicted of, or ended a period of incarceration resulting from a conviction for a misdemeanor other than a first conviction of drunkenness, simple assault, minor traffic violations, affray or disturbance of the peace? *   Yes    No If yes, describe in full: Have you at any time been convicted of a misdemeanor other than such first conviction? *   Yes    No If yes, describe in full: Note: a conviction record will not necessarily, be a bar to employment..... *An applicant for employment with a sealed record on file......  2.04.P01.F04

Education and Training
Type of School Name & Location Number of Years Completed Graduated? Type of Degree, Diploma, & Cert. Major/Minor Field of Study High School* 01234Other  Yes  No College or University 01234Other  Yes  No Other Education 01234Other  Yes  No

Employment Experience Please furnish us with a complete record of your employment for the past ten years. Begin with your last employer. Include US Military Service, previous Mid Cape Home Centers experience, summer / part-time jobs, volunteer work, and cooperative education assignments. We contact previous employers for reference checks. 1. Dates Worked: From:* To:* Supervisor's Name and Title:* Employer's Name:* Employer's Address:* Employer's Telephone:* Salary: Starting:* Final:* Other Compensation: Your Job Title:* Your Job Duties:* Reason for Leaving:* 2. Dates Worked: From: To: Supervisor's Name and Title: Employer's Name: Employer's Address: Employer's Telephone: Salary: Starting: Final: Other Compensation: Your Job Title: Your Job Duties: Reason for Leaving: 3. Dates Worked: From: To: Supervisor's Name and Title: Employer's Name: Employer's Address: Employer's Telephone: Salary: Starting: Final: Other Compensation: Your Job Title: Your Job Duties: Reason for Leaving: 4. Dates Worked: From: To: Supervisor's Name and Title: Employer's Name: Employer's Address: Employer's Telephone: Salary: Starting: Final: Other Compensation: Your Job Title: Your Job Duties: Reason for Leaving: 5. Dates Worked: From: To: Supervisor's Name and Title: Employer's Name: Employer's Address: Employer's Telephone: Salary: Starting: Final: Other Compensation: Your Job Title: Your Job Duties: Reason for Leaving:   If you have had other forms of compensation such as bonuses, commissions, etc., please note   If you are now employed, may we contact your current employer?:    Yes    No   May we contact your previous employers?:    Yes    No   Do you have any outside business or employment activities that you intend to continue if you are employed by Mid Cape Home Centers?    Yes    No   Unemployment Record Account here for all intervals of unemployment during the past ten years , if any, from the month and year you left school to the present. From Mo/YR To Mo/YR State what you were doing

Business References Only Name Address Occupation Telephone Number Years Known *

PLEASE READ THE FOLLOWING STATEMENT CAREFULLY 1. I authorize the persons, schools, and employers named in this application to provide Mid Cape Home Centers with any relevant information that may be required to arrive at an employment decision. 2. I understand and agree that: The information that I have provided is accurate to the best of my knowledge and is subject to verification by Mid Cape Home Centers. A material misrepresentation or deliberate omission of a fact in my application may be justification for refusal of employment, or if employed, termination by Mid Cape Home Centers. Although management makes every effort to accommodate individual preferences, business needs at times make the following conditions mandatory: overtime, shift work, a rotating work schedule other than Monday through Friday. I understand and accept these conditions of my continuing employment. 3. I understand that nothing contained in this employment application or in the granting of an interview is intended to create an employment contract between Mid Cape Home Centers Inn and myself for either employment or for the providing of benefit. No promise regarding continued employment has been made to me and I understand that no such promise or guarantee is binding upon Mid Cape Home Centers unless made in writing. I understand and agree to the above statement* It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment. An employer who violates this law shall be subject to criminal penalties and civil liability.