Online Application

First Name Last Name Middle

Street Address Mailing (if Different)

City State Zip County Email Address

Home Phone:   Phone (cell): How did you here about us? Ad HCM Employee Job Fair Agency On Own Internet, Website

Referral Name: (i.e. name of newspaper, agency, employee, etc.)

If you have any relatives currently working for Home Care for Maine, please list:

Have you ever worked for Home Care for Maine before? yes no If yes, when?
(formerly Home Resources of Maine, Inc.)

Position applying for? (Personal Support Specialist)       #Hrs willing to work per week
Min. salary requirement /Hr    Date available

Please enter the start and end times you can commit to on each day you are available to work:
Monday                 Tuesday            Wednesday            Thursday            Friday              Saturday            Sunday
                                      

What towns are you willing to work in?

Do you have any commitments to another employer that might affect your employment with us?

Please list any related skills, experiences or qualifications:

Have you ever been convicted of a criminal offense? HCM does background checks back to 18 years of age. (Please consider anything that may have occurred in your past such as paying a fine or serving jail time).
Answer yes or no.
If yes, please explain offense(s) and dates:

Regarding the Board of Nursing, CNA Registry or Department of Licensing and Certification, do you have any sanctions against your license or certificate? yes no If yes, explain:

EDUCATION

Elementary School Name & Address:

Last Year Completed: 1 2 3 4 5 6 7 8 Did you graduate? yes no List Diploma or Degree:

High School Name & Address: Course of Study:

Last Year Completed: 9 10 11 12 Did you graduate? yes no List Diploma or Degree:

College Name & Address: Course of Study:

Years Completed: 1 2 3 4 5 6 7 8 Did you graduate? yes no List Diploma or Degree:

Other (Specify) School Name & Address: Course of Study:

Years Completed: 1 2 3 4 5 6 7 8 Did you graduate? yes no List Diploma or Degree:

Are you legally authorized to work in the United States? yes no Are you at least 18 years of age? yes no

Some of the essential job functions include but are not limited to: twisting, bending, walking, reaching over the head, climbing stairs, driving, pushing, pulling, sitting, standing and lifting up to 20 lbs. Do you have the ability to perform the essential job functions for which you are applying? yes no

Do you have reliable Transportation? yes no

EMPLOYMENT HISTORY
To ensure prompt processing of your application, please fill out your employment history completely.
List present employer or most recent first.

Employer: Address: Dates Employed:

Your Job Title: Supervisor's Name: Telephone:

Starting Salary:    Ending Salary:      Job Duties:

Reason for Leaving:

Employer: Address: Dates Employed:

Your Job Title: Supervisor's Name: Telephone:

Starting Salary:    Ending Salary:      Job Duties:

Reason for Leaving:

Employer: Address: Dates Employed:

Your Job Title: Supervisor's Name: Telephone:

Starting Salary:    Ending Salary:      Job Duties:

Reason for Leaving:

 Read Carefully: I authorize the release of information by previous and present employers, schools, persons or investigating bureaus needed to provide relevant information required to arrive at an employment decision.

Signature and Date:

Read Carefully:  The facts set forth in my application for employment are true and complete. I understand that if employed, any false statements on this application may result in dismissal. I further understand that this application is not and is not intended to be a contract of employment, nor does this application obligate the employer in any way if the employer decides to employ me. In the event I am offered a position with Home Care for Maine, I give permission to Home Care for Maine to perform a criminal background and motor vehicle record check.  I understand and agree that my employment is at will and can be terminated by either party for any reason or no reason. No one other than an officer of the agency has any authorization to enter into any agreement for employment for any specified period of time. 

Signature of Applicant and Date: