State of Maine Employment Application

State of Maine
(An Equal Opportunity Employer)
Employment Application
(revised December 2008)
Last Name
First Name
M.I.
Social Security
Number
Have you ever worked, attained licensing or certification, attended school or been convicted of a criminal offense under a
different name?
Yes No If so, what is that name?
Name #1
_________________________________
Name #2
_________________________________
Name #3
_________________________________
Name #4
_________________________________
Mailing Address
State
Town
Home Phone #
Work Phone #
ZIP Code
Email Address
Title of the Job You’re Applying For
Job Class Code
Veteran’s Preference: See pamphlet “Veteran’s Preference in Maine State Service” or go to
www.maine.gov/bhr/state_jobs/veteran.htm for more information. Provide DD214 and disability forms if applicable.
Not Claimed
5 Points (Requires DD214)
10 Points (Requires DD214 and VA Statement of Disability)
Only U.S. citizens or aliens who have a legal right to work and remain permanently in the U.S. are eligible for
employment. Can you, after employment, submit verification of your legal right to work in the United States?
Yes
No
Are you at least 18 years of age?
Yes
No
Are you a present or former Maine State employee?
Yes
No
Department
___________________
Job Title
___________________________________
Are you willing to work:
Saturdays
Sundays
Yes
Do you have a current Maine driver’s license?
If yes, what type?
Class A
Class B
Are you willing to travel on the job?
Yes
Begin Date
______________
End Date
______________
Holidays
No
Class C
No
If yes, are you willing to use your own vehicle?
Yes
No
Are you willing to work overtime? Yes No What shifts are you willing to work? 1st 2nd 3rd
ADMINISTRATIVE SKILLS (subject to formal testing and work sampling) WORDS PER MINUTE
Typewriter:
Keyboarding:
FOREIGN LANGUAGE SKILLS
Language __________________________
Speak Read Write Language __________________________
Speak Read Write Page 1 of 8
PER 3 - 12/08
Geographic Preference
Candidates are asked to specify the geographic areas of the State in which they will accept employment by completing the
form below. You may select or change the conditions of your referral by checking the appropriate boxes. Mark the
area(s) and condition(s) of employment suitable to you. If you do not select any areas, the bureau will automatically
refer your name for all counties and employment types.
F = Full Time
F
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
16
17
18
19
20
All Counties
Androscoggin
Lewiston
Livermore
Aroostook
Ashland
Caribou
Fort Kent
Houlton
Madawaska
Presque Isle
Van Buren
Cumberland
Portland
Brunswick
South Portland
Windham MCC
Franklin
Farmington
Rangeley
P
T
P = Part Time
T = Temporary
S
F
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
P
T
S=Seasonal
S
Hancock
Bar Harbor
Bucksport
Ellsworth
Kennebec
Augusta
Augusta-RPC
Waterville
Knox
Rockland
Thomaston
Lincoln
Boothbay
Oxford
Norway
Rumford
Penobscot
Bangor
Bangor BMHI
Charleston
Millinocket
F
42
43
44
45
46
48
49
50
51
52
53
54
55
56
57
58
59
60
61
P
T
Piscataquis
Dover-Foxcroft
Greenville
Sagadahoc
Bath
Somerset
Skowhegan
Waldo
Belfast
Washington
Bucks Harbor
DCF
Calais
Eastport
Machias
York
Biddeford
Kittery
Saco
Sanford
Education
Last Yr
Completed
Name and Location
Sem
Hrs
Qtr
Hrs
Major
Minor
Yr
Of
Deg
Degree
Type
High School
1 2 3 4
College or
University
1 2 3 4
Grad School
1 2 3 4
Prof School
1 2 3 4
Other
1 2 3 4
Page 2 of 8
PER 3 - 12/08
S
Licenses, Certifications and Registrations
Name of License,
Registration or
Certification
License Number
State of Issue
Expiration Date
Important instructions for Completing Employment History
This portion must be accurate and complete. APPLICATIONS LACKING SUFFICIENT INFORMATION WILL BE
REJECTED. List your entire work history including part-time, temporary and volunteer jobs. List jobs in
reverse order, starting with your present or last job. List each promotion as a separate job. To evaluate your
qualifications we must have accurate and complete information on previous job tasks and levels of
responsibility. Part or all of your examination score may be based on your work history. Be thorough and
specific in the detailing of duties. SPECIAL NOTE: If additional space is needed, attach separate sheets.
Employer #1
From (mm/yy):
To (mm/yy):
______________________ - ______________________
Complete Address and phone number:
Last Weekly Pay $
Your Title:
Hours/Week:
Number & Titles of Employees You Supervised:
Supervisor’s Name & Title:
Duties:
Reason for Leaving:
Employer #2
From (mm/yy):
To (mm/yy):
______________________ - ______________________
Complete Address and phone number:
Last Weekly Pay $
Your Title:
Hours/Week:
Number & Titles of Employees You Supervised:
Supervisor’s Name & Title:
Duties:
Page 3 of 8
PER 3 - 12/08
Employer #3
From (mm/yy):
To (mm/yy):
______________________ - ______________________
Complete Address and phone number:
Last Weekly Pay $
Your Title:
Hours/Week:
Number & Titles of Employees You Supervised:
Supervisor’s Name & Title:
Duties:
Employer #4
From (mm/yy):
To (mm/yy):
______________________ - ______________________
Complete Address and phone number:
Last Weekly Pay $
Your Title:
Hours/Week:
Number & Titles of Employees You Supervised:
Supervisor’s Name & Title:
Duties:
Employer #5
From (mm/yy):
To (mm/yy):
______________________ - ______________________
Complete Address and phone number:
Last Weekly Pay $
Your Title:
Hours/Week:
Number & Titles of Employees You Supervised:
Supervisor’s Name & Title:
Duties:
Employer #6
From (mm/yy):
Complete Address and phone number:
Last Weekly Pay $
Your Title:
Hours/Week:
Number & Titles of Employees You Supervised:
Supervisor’s Name & Title:
To (mm/yy):
______________________ - ______________________
Duties:
Page 4 of 8
PER 3 - 12/08
Employer #7
From (mm/yy):
To (mm/yy):
______________________ - ______________________
Complete Address and phone number:
Last Weekly Pay $
Your Title:
Hours/Week:
Number & Titles of Employees You Supervised:
Supervisor’s Name & Title:
Duties:
Employer #8
From (mm/yy):
To (mm/yy):
______________________ - ______________________
Complete Address and phone number:
Last Weekly Pay $
Your Title:
Hours/Week:
Number & Titles of Employees You Supervised:
Supervisor’s Name & Title:
Duties:
Employer #9
From (mm/yy):
To (mm/yy):
______________________ - ______________________
Complete Address and phone number:
Last Weekly Pay $
Your Title:
Hours/Week:
Number & Titles of Employees You Supervised:
Supervisor’s Name & Title:
Duties:
Employer #10
From (mm/yy):
Complete Address and phone number:
Last Weekly Pay $
Your Title:
Hours/Week:
Number & Titles of Employees You Supervised:
Supervisor’s Name & Title:
To (mm/yy):
______________________ - ______________________
Duties:
Page 5 of 8
PER 3 - 12/08
The State of Maine conducts background checks.
Have you ever been convicted of any violation of law by any court of law? Include any guilty pleas entered,
military courts martial, traffic violation convictions for Operating Under the Influence (OUI), or traffic
violations that resulted in your license being suspended. Do not include any conviction(s) occurring before
your 18th birthday or traffic violations not listed above.
Please print your answer (either “Yes” or “No”) in the space provided: __________
If yes, please list: Offense(s)
Date of Conviction(s)
___________________________________________________
__________________
___________________________________________________
__________________
___________________________________________________
__________________
___________________________________________________
__________________
Not all conviction(s) will automatically disqualify you from employment but will be considered in relation to
specific job requirements. Omission or misrepresentation of this information will result in employment
ineligibility.
--------------------------------------------------------------------------------------------------------------Please read and sign the following statement: I certify, under penalty of law, that the
information given in this application is correct and complete to the best of my knowledge. I am
aware that, should investigation at any time show falsification, I will not be considered for
employment or, if employed, I may be dismissed. I hereby authorize the State of Maine, the
Department of Administrative and Financial Services, Bureau of Human Resources and agencies to
whom my name is certified/referred to make all necessary investigations concerning me, my work
habits, character, or my action in any transaction. I authorize the State of Maine to check my
driving record if the position for which I am applying requires driving. I understand that I may be
asked to submit to a pre-employment drug test, a credit history check and/or a criminal history
background check as a condition of employment. I authorize the Bureau of Human Resources or its
assignee to receive and make available to other state agencies my academic records or other
material pertinent to my qualifications, and further authorize and request each former employer,
person given as reference, educational institution or organization (including law enforcement
agencies) to provide all information that may be sought in connection with my application. I
understand and agree that I will be required to ratify the information contained in this application
by signature as a condition of employment.
Signature_______________________________________________ Date __________________
Page 6 of 8
PER 3 - 12/08
Date Stamp
Human Resources Use Only
Closing Date
Date Sent:
1
Supplemental Questions
Date Due:
2
Qualified
Review
Initials
Date
3
Not Qualified
Conditionally Qualified
Exam
Components
%
Date
Results Record
Reason
Comments
MERS
T&E
Written
PAT
Oral
Convert Score From
Service Rating
1 Performance
2 Performance
Entry control Label
AGENCY PERSONNEL USE ONLY
Minimum Qualifications
Pass
Testing Record
Hired in Classification
Title
Fail
Date
Rater’s Name
Results
Agency
Effective Date
Page 7 of 8
Position Number
PER 3 - 12/08
APPLICANT INFORMATION SURVEY
INSTRUCTIONS TO THE APPLICANT: The State of Maine is an Equal Opportunity Employer. The information solicited on this page is being compiled by the Maine
Bureau of Human Resources to comply with Federal record-keeping regulations and EEO/Affirmative Action requirements. You are not required to furnish this
information, but your cooperation is encouraged. The information on this form is CONFIDENTIAL. The page will be removed from your application prior to review
and destroyed after data compilation.
1. I have read the paragraph above and do not
wish to provide the information.
RACIAL/ETHNIC DEFINITIONS
0. WHITE (not of Hispanic Origin): All persons having origins in any of the
original peoples of Europe, North Africa, or the Middle East.
1. BLACK (not Hispanic Origin): All persons having origins in any of the Black
racial groups of Africa.
2. HISPANIC: All persons of Mexican, Puerto Rican, Cuban, Central or South
American, or other Spanish culture or origin, regardless of race.
3. ASIAN OR PACIFIC ISLANDERS: All persons having origins in any of the
original peoples of the Far East, Southeast Asia, the Indian subcontinent, or the
Pacific Islands. This area includes, for example, China, Japan, Korea, the Philippine
Islands, and Samoa.
4. AMERICAN INDIAN OR ALASKAN NATIVE: All persons having origins in
any of the original peoples of North America, and who maintain cultural
identification through tribal affiliation or community recognition.
6. OTHER
DEFINITIONS OF VETERANS SUBJECT TO EEO/AFFIRMATIVE
ACTION REGULATIONS:
(The requirements are different from State Veterans Preference)
VIETNAM ERA VETERAN: One who served on active duty for more than 90 days,
any part of which occurred between August 5, 1964 and July 7, 1975 and was
discharged or released other than a dishonorable discharge, or was discharged or
released from active duty for a service-connected disability if any part of such active
duty was performed between August 5, 1964 and July 7, 1975.
DISABLED VETERAN: A person entitled to disability compensation under laws
administered by the Veterans Administration for a disability rated at 30 per cent or
more, or a person whose release from active duty was for a disability incurred or
aggravated in the line of duty.
(month) (day)
-
2. Enter your date of birth
(year)
3. Enter your racial/ethnic group code number
(refer to definitions at left)
4. What is your sex?
A. Female
B. Male
PLEASE PLACE AN X IN ALL BOXES WHICH APPLY TO YOU (refer
to definitions at left)
5. Vietnam Era Veteran
6. Disabled Veteran
PLEASE PLACE AN X IN ALL BOXES WHICH APPLY TO YOU (refer
to definitions at left)
DEFINITION FOR DISABILITY
Any person who has a physical or mental impairment which substantially limits one
or more of such person’s major life activities, has a record of such impairment, or is
regarded as having such impairment has a disability under the Americans With
Disabilities Act. Major life activities include: walking, seeing, hearing, learning,
self-care, speaking, lifting, reaching, thinking performing manual tasks, breathing,
working and interacting with others.
Page 8 of 8
7. Have a disability as defined
8. Interview accommodations may be necessary
due to a disability
PER 3 - 12/08