State of Maine Employment Application		
First Name:	     	Last Name: 	     	
Email: 	     	
Mailing Address:	     	Town:	     	State:	    	Zip:	     	
Phone Number: 	     	

Are you a current or former employee of the State of Maine?  Yes    No 
If Yes, agency previously worked at:       	
Name 1:	     	Name 3: 	     	
Name 2:	     	Name 4: 	     	
Job title you are applying for:	     	
How did you hear about this position?	     	

Are you at least 18 years of age?             Yes No
Do you have a valid driver’s license?       Yes No   State Issued:      
If Yes; which type:  Class A  Class B Class C
List your geographical location preference (i.e. Augusta/Kennebec County; Portland/Cumberland County etc.)      
Are you willing to work overtime? Yes No   What shifts are you willing to work?  1st 2nd 3rd 	
Veteran’s Preference: Maine law provides a preference to qualified veterans and Gold Star spouses by ensuring they are offered an interview. If you are a veteran or a Gold Star spouse and wish to take advantage of this preference, please indicate by checking the appropriate box below. Documentation is required, submit appropriate form with this application. For more information, visit the following website: http://www.maine.gov/bhr/state_jobs/veteran.htm  
 Not Claimed
 Veteran (requires DD Form 214)
 Gold Star Spouse (requires DD form 1300)	
Disability Preference: Maine law provides a hiring preference to persons with disabilities by ensuring that one person with a disability is offered an interview if they meet the minimum qualifications of this position. If you believe that you qualify and wish to request a disability preference, please indicate by checking the appropriate box below. For more information on the Disability Preference, visit: http://legislature.maine.gov/statutes/5/title5sec7054-C.html 
 Claimed
 Not Claimed	
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     

Please attach a cover letter and resume containing your work history (including month/year worked, full time or part time), and any additional documentation requested in the Job Bulletin
-OR-
Use the attached Employment-Education History form.	
	
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 court martial, traffic violation convictions for Operating Under the Influence (OUI), or traffic violations that resulted in your license being suspended.  Do not include here any juvenile adjudications or traffic violations not listed above.  Some positions require disclosure of juvenile adjudications.  Applicants for these positions will be required to disclose juvenile adjudications on a supplemental form provided for that purpose.
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) or adjudication(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 and supporting documents (resume/cover letter etc.) are 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      ____________	

Important Instructions for Completing Employment-Education History	
To evaluate your qualifications, please provide accurate and complete information regarding your education, previous job tasks and levels of responsibility.  Your qualifications may be based on relevant work history, to include part time, Temporary and Volunteer experience.  Be thorough and specific in the detailing of duties.

Please complete the form below (attach additional documentation if needed), or attach a resume containing your work history to include years worked at each employer.	
Education	
	Name and Location	Credit Hours	Major	Minor	Graduate? /Degree Type	
High School	     	     	     	     	     	
College/University	     	     	     	     	     	
Grad School	     	     	     	     	     	
Prof School	     	     	     	     	     	
Other	     	     	     	     	     	
Licenses, Certifications and Registrations	
Name of License, Certification or Registration 	License Number	State of Issue	Expiration Date	
     	     	     	     	
     	     	     	     	
     	     	     	     	
     	     	     	     	
Employment History	
Employer # 1:	     	From:	Month/Year
     	To:	Month/Year
     	
Complete Address and Phone Number:	     	
Your Title	     	Weekly Hours Worked:	     	
Your Supervisor’s Name & Title:	     	
Duties:	     	
Reason for Leaving:	     	
Employer # 2:	     	From:	Month/Year
     	To:	Month/Year
     	
Complete Address and Phone Number:	     	
Your Title	     	Weekly Hours Worked:	     	
Your Supervisor’s Name & Title:	     	
Duties:	     	
Reason for Leaving: 	     	

Employer # 3:	     	From:	Month/Year
     	To:	Month/Year
     	
Complete Address and Phone Number:	     	
Your Title	     	Weekly Hours Worked:	     	
Your Supervisor’s Name & Title:	     	
Duties:	     	
Reason for Leaving:	     	
Employer # 4:	     	From:	Month/Year
     	To:	Month/Year
     	
Complete Address and Phone Number:	     	
Your Title	     	Weekly Hours Worked:	     	
Your Supervisor’s Name & Title:	     	
Duties:	     	
Reason for Leaving:	     	
Employer # 5:	     	From:	Month/Year
     	To:	Month/Year
     	
Complete Address and Phone Number:	     
	
Your Title	     	Weekly Hours Worked:	     	
Your Supervisor’s Name & Title:	     	
Duties:	     	
Reason for Leaving:	     	

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.	

RACIAL/ETHNIC DEFINITIONS

0.  WHITE:  A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
1.  BLACK or AFRICAN AMERICAN:  A person having origins in any of the black racial groups of Africa.
2.  HISPANIC or LATINO:  A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.
3.  ASIAN:  A person having origins in any of the original peoples of the Far East, Southeast Asia, the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
4.  AMERICAN INDIAN OR ALASKA NATIVE:  A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment.
5.  Not Coded (Not Reported)
6.  NATIVE HAWAIIAN or OTHER PACIFIC ISLANDER:  A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
7.  TWO OR MORE RACES:  All persons who identify with more than one of the above races.
	
    1.  I have read the paragraph above and do not  wish to provide the information.

       2.  Enter your date of birth
(month) (day) (year)	
	                           
   3. Enter your racial/ethnic group code number (refer to definitions at left)  
	
	  4.  What is your sex?     A.  Female     B.  Male

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 percent or more, or a person whose release from active duty was for a disability incurred or aggravated in the line of duty.	PLEASE PLACE AN X IN ALL BOXES WHICH APPLY TO YOU (refer to definitions at left)

  5.  Vietnam Era Veteran

  6.  Disabled Veteran

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.  

	PLEASE PLACE AN X IN ALL BOXES WHICH APPLY TO YOU (refer to definitions at left)

                                   

  7.  Have a disability as defined

  8.  Interview accommodations may be necessary due to a disability