ࡱ> q  <bjbjt+t+ )AAb"]$$$$8\<$@? L>| =======$2@&Bl>)?"?"?">W3 W3W3W3?"=,,?"=W3W3k8n<=L4@8"k$$*= H.R. Department Location: 304 Hancock St., Suite. 2C, Bangor Fax: 207-942-9290 Phone: 207-947-0366 TYY: 207-990-4730 In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for positions without regard to race, color, sex, religion, age, ancestry or national origin, sexual orientation, or physical or mental disability. THIS FORM MUST BE COMPLETED IN FULL. Do not leave spaces blank with a note to see resume. Date of Application: FORMTEXT      Position(s) Applied For FORMTEXT      Desired Location(s) FORMTEXT      Name FORMTEXT      Phone #  FORMTEXT      Address FORMTEXT      City/ State/ Zip Code FORMTEXT      Do you have a legal right to work in the United States?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoAre you 18 years of age or older?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoHave you ever worked for this agency before?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, Where? FORMTEXT       Dates: From: FORMTEXT      To: FORMTEXT      Position Held: FORMTEXT      Referral Source:  FORMCHECKBOX  Newspaper  FORMCHECKBOX  Current Employee  FORMCHECKBOX  Radio  FORMCHECKBOX  CHCS Web Site  FORMCHECKBOX  Walk-in  FORMCHECKBOX   FORMTEXT      When are you available for employment? FORMTEXT      Are you able to work FORMCHECKBOX  Full Time FORMCHECKBOX  Part TimeCan you travel if a job requires it? FORMCHECKBOX  Yes FORMCHECKBOX  NoCan you provide your own transportation? FORMCHECKBOX  Yes FORMCHECKBOX  NoIf you respond yes to any of the following five questions, please provide a brief explanation on page 4.Have you ever been the subject of a child or adult abuse allegation or complaint? FORMCHECKBOX  Yes FORMCHECKBOX  NoHave you ever been convicted of a crime? (Includes felony, misdemeanor, OUI) FORMCHECKBOX  Yes FORMCHECKBOX  NoIs there a criminal action currently pending against you? FORMCHECKBOX  Yes FORMCHECKBOX  No Have you been the subject of any protection from abuse orders, or any other types of orders involving domestic violence within the past five years? FORMCHECKBOX  Yes FORMCHECKBOX  NoHave you ever, in this state or any other state, had a license or certificate (e.g. professional license, drivers license) revoked or suspended, or have you ever voluntarily surrendered a license or certificate? FORMCHECKBOX  Yes FORMCHECKBOX  No Education, Work and Military ExperienceWhen listing education, if you have not completed a degree program indicate how much is completed, based on full- time attendance (i.e., 15 credit hours per semester). Start with most recent position and move backward through all positions and military service for the past twenty years. You may exclude employment during high school. Include the month and year you began and ended each position. This is vital for potentially calculating a salary quote. Furnish dates and explanations for each period of unemployment of one month or more. You may attach a resume for supplemental information related to volunteer work, memberships, associations, etc. Use the space on page 4 for additional information and copy page 3 as needed for additional positions.  Name of SchoolCity, StateCurrent Status (e.g., 1st yr., etc.)Degree AwardedType (e.g., BS, MSW)MajorHigh School or Equivalency FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  Yes FORMTEXT       FORMTEXT      Post Secondary: FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  Yes FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  Yes FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  Yes FORMTEXT       FORMTEXT       Professional license(s) or certification(s) currently held (include numbers if applicable): FORMTEXT       FORMTEXT       Employer: FORMTEXT      Present or last position: FORMTEXT      Address: FORMTEXT      Employed from: FORMTEXT      To: FORMTEXT      Salary: FORMTEXT      Aver. Hrs./Wk. FORMTEXT    Responsibilities: FORMTEXT       FORMTEXT       FORMTEXT      Reason for leaving: FORMTEXT      If currently employed, may we contact?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoSupervisor/Contact Person: FORMTEXT      Phone Number: FORMTEXT      Employer: FORMTEXT      Position: FORMTEXT      Address: FORMTEXT      Employed from: FORMTEXT      To: FORMTEXT      Salary: FORMTEXT      Aver. Hrs./Wk. FORMTEXT    Responsibilities: FORMTEXT       FORMTEXT       FORMTEXT      Reason for leaving: FORMTEXT      Supervisor/Contact Person: FORMTEXT      Phone Number: FORMTEXT       Employer: FORMTEXT      Position: FORMTEXT      Address: FORMTEXT      Employed from: FORMTEXT      To: FORMTEXT      Salary: FORMTEXT      Aver. Hrs./Wk. FORMTEXT    Responsibilities: FORMTEXT       FORMTEXT       FORMTEXT      Reason for leaving: FORMTEXT      Supervisor/Contact Person: FORMTEXT      Phone Number: FORMTEXT      Employer: FORMTEXT      Position: FORMTEXT      Address: FORMTEXT      Employed from: FORMTEXT      To: FORMTEXT      Salary: FORMTEXT      Aver. Hrs./Wk. FORMTEXT    Responsibilities: FORMTEXT       FORMTEXT       FORMTEXT      Reason for leaving: FORMTEXT      Supervisor/Contact Person: FORMTEXT      Phone Number: FORMTEXT      Employer: FORMTEXT      Position: FORMTEXT      Address: FORMTEXT      Employed from: FORMTEXT      To: FORMTEXT      Salary: FORMTEXT      Aver. Hrs./Wk. FORMTEXT    Responsibilities: FORMTEXT       FORMTEXT       FORMTEXT      Reason for leaving: FORMTEXT      Supervisor/Contact Person: FORMTEXT      Phone Number: FORMTEXT      Employer: FORMTEXT      Position: FORMTEXT      Address: FORMTEXT      Employed from: FORMTEXT      To: FORMTEXT      Salary: FORMTEXT      Aver. Hrs./Wk. FORMTEXT    Responsibilities: FORMTEXT       FORMTEXT       FORMTEXT      Reason for leaving: FORMTEXT      Supervisor/Contact Person: FORMTEXT      Phone Number: FORMTEXT       Use this space for additional information: FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       ~ Applicant s Statement ~ (This statement is only valid when signed exactly as printed on this form.) I certify that the information contained in this application is correct and complete to the best of my knowledge and belief. I understand that if I am hired, any false or misleading statement or omission of material fact may lead to dismissal. I authorize Community Health and Counseling Services (CHCS) to verify all statements contained in this application and to make any necessary job related reference checks. I certify that I am in sufficiently good physical, mental, and emotional health to carry out the duties of this position if I am hired. I authorize the employers, supervisors, and references provided or discovered during my application process to give CHCS any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release all parties from all liability for any damage or injury that may result from furnishing same to CHCS. I understand that an offer of employment may be conditioned on the results of a medical examination and background checks. I understand that pre-employment reference checks will not be considered as part of my personnel record if I am hired, and that they will remain confidential and unavailable for my review.   FORMTEXT      Signature of Applicant Date Print Name HR #11 (Revised 6/04) Page  PAGE 4 of  NUMPAGES 1  Community Health And Counseling Services P.O. 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