Department of Health and Human Services
State of Maine
Application/Attendance Form
Dorothea Dix Psychiatric Center (formerly known as Bangor Mental Health Institute)
656 State Street
BANGOR, MAINE 04402
or PO Box 926 Bangor, ME 04402
STAFF EDUCATION
And TRAINING UNIT
SETU E-mail address
DHS.SETU@MAINE.GOV
Phone # 287-9355
TTY: 1-800-606-0215 (Deaf/Hard of Hearing)
This must be the name you use for the personnel office.
Name:
Last First MI
Dorothea Dix Psychiatric Center (formerly known as Bangor Mental Health Institute) 656 State St BANGOR, MAINE 04101
Day time phone number: EXT:
TAMS #
E-mail Address:
B. Do you need special accommodations for a disability? Yes No (Please specify)
CANCELLATION POLICY: A Confirmation notice will be sent to you about two months prior to a program if you are accepted. You must cancel prior to the program by phone, fax, or e-mail. E-mail is the most accurate way to assure we receive notification. After two "no-shows", participants will be ineligible for one year of SETU programs. (I have read and understood this policy? Yes)
E. Please check the type of position which you now hold: (Check all that apply to you) Administrator Supervisor Clerical Direct Services Other
F. Please indicate Class Title, Class Number, Location, and Date:
Class Title:
ID Number:
Location:
Dates:
Supervisor's E-mail Address:
If your application is accepted, you will be notified no later than two weeks prior to the beginning of the selected program.
You will NOT be notified if your application is denied.
If you have any questions concerning this form, please contact us at 287-9355.
