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:       	

Have you ever worked, attained licensing or certification, attended school or been convicted of a criminal offense under a different name?    Yes    No 
If Yes, list name(s) below:	
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. 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)	
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.	
Voluntary Identification of Disability
Applicants who self-identify as having a disability may increase their likelihood of being interviewed for vacancies. You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history of such impairment or medical condition.
	Not claimed
	Yes, I have a disability

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 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:	     	To:	     	
Complete Address and Phone Number:	     	
Your Title	     	Weekly Hours Worked:	     	
Your Supervisor’s Name & Title:	     	
Duties:	     	
Reason for Leaving:	     	
Employer # 2:	     	From:	     	To:	     	
Complete Address and Phone Number:	     	
Your Title	     	Weekly Hours Worked:	     	
Your Supervisor’s Name & Title:	     	
Duties:	     	
Reason for Leaving: 	     	

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