State of Maine
(An Equal Opportunity Employer)

Employment Application
(revised February 2011)
		
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?   
                                       c Yes   c No   If so, what is that name?	
Name #1
             _________________________________	Name #2
             _________________________________	
Name #3
             _________________________________	Name #4
             _________________________________	
Mailing Address
	Town
	State
	ZIP Code
	
Home Phone #
	Work Phone #
	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/state_jobs/veteran.htm for more information. Provide DD214 and disability forms if applicable.

     c   Not Claimed
     c   5 Points (Requires DD214)
     c  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?

              c Yes  c No	
Are you at least 18 years of age?    c   Yes    c   No	
Are you a present or former Maine State employee?   c   Yes    c   No	
Department
___________________	Job Title
___________________________________	Begin Date
______________	End Date
______________	
Are you willing to work:    c  Saturdays    c  Sundays    c  Holidays	
Do you have a current Maine driver’s license?   c  Yes   c  No	
If yes, what type?    c  Class A   c  Class B   c  Class C	
Are you willing to travel on the job?   c  Yes   c  No	
If yes, are you willing to use your own vehicle?   c  Yes   c  No	
Are you willing to work overtime?  c Yes  c No  What shifts are you willing to work?  c 1st  c 2nd  c  3rd	
ADMINISTRATIVE SKILLS (subject to formal testing and work sampling) WORDS PER MINUTE	
Typewriter:  	Keyboarding:  	
FOREIGN LANGUAGE SKILLS	
	Language  __________________________	Speak c	Read  c	Write  c	
	Language  __________________________	Speak c	Read  c	Write  c	

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        P = Part Time        T = Temporary        S=Seasonal
	
		F	P	T	S			F	P	T	S			F	P	T	S	
0	All Counties					21	Hancock					42	Piscataquis					
1	Androscoggin					22	Bar Harbor					43	Dover-Foxcroft					
2	Lewiston					23	Bucksport					44	Greenville					
3	Livermore					24	Ellsworth					45	Sagadahoc					
4	Aroostook					25	Kennebec					46	Bath					
5	Ashland					26	Augusta					48	Somerset					
6	Caribou					27	Augusta-RPC					49	Skowhegan					
7	Fort Kent					28	Waterville					50	Waldo					
8	Houlton					29	Knox					51	Belfast					
9	Madawaska					30	Rockland					52	Washington					
10	Presque Isle					31	Thomaston					53	Bucks Harbor DCF					
11	Van Buren					32	Lincoln					54	Calais					
12	Cumberland					33	Boothbay					55	Eastport					
13	Portland					34	Oxford					56	Machias					
14	Brunswick					35	Norway					57	York					
16	South Portland					36	Rumford					58	Biddeford					
17	Windham MCC					37	Penobscot					59	Kittery					
18	Franklin					38	Bangor					60	Saco					
19	Farmington					39	Bangor BMHI					61	Sanford					
20	Rangeley					40	Charleston											
						41	Millinocket											

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								

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: 	

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):                        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 #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):                        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: 	

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 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 __________________	

Human Resources Use Only	
Date Stamp	
Review	Initials	Date	  Closing Date                         Date Sent:

  Supplemental Questions      Date Due:		
1					
2			  Qualified                 

  Conditionally Qualified	  Not Qualified

   Reason		
3						
Exam Components	%	Date	Results	Record	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 Fail	Date	Rater’s Name		
Testing Record	Results		

			
Hired in Classification Title	Agency	Effective Date	Position Number		

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 (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	
    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 per cent 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