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Bureau of Human Resources

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Bureau of Human Resources

    Bureau of Human State of Maine Resources

    (An Equal Opportunity Employer)

    #4 State House Station Augusta, ME 04333-0004

     Employment Application Tel:(207)624-7761 (revised December 2008) TTY:(888)557-6690

    Social Security Last Name First Name M.I. Number Have you ever worked, attained licensing or certification, attended school or been convicted of a criminal offense under a

    different name?

     Yes No If so, what is that name?

    Name #1 Name #2

Name #3 Name #4

    State Mailing Address Town 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/bhr/state_jobs/veteran.htm for more information. Provide DD214 and disability forms if applicable.

     Not Claimed

     5 Points (Requires DD214)

     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?

     Yes No

    Are you at least 18 years of age? Yes No

    Are you a present or former Maine State employee? Yes No

    Department Job Title Begin Date End Date

Are you willing to work: Saturdays Sundays Holidays

    Do you have a current Maine driver’s license? Yes No

    If yes, what type? Class A Class B Class C

    Are you willing to travel on the job? Yes No

    If yes, are you willing to use your own vehicle? Yes No

    stndAre you willing to work overtime? Yes No What shifts are you willing to work? 1 2 3rd ADMINISTRATIVE SKILLS (subject to formal testing and work sampling) WORDS PER MINUTE Typewriter: Keyboarding:

    FOREIGN LANGUAGE SKILLS

     Language Speak Read Write

     Language Speak Read Write

     Page 1 of 9 PER 1 - 12/08

    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

    Yr Last Yr Sem Qtr Degree Name and Location Major Minor Of Completed Hrs Hrs Type Deg

     High School

     College or University

     Grad School

     Prof School

     Other

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    Licenses, Certifications and Registrations

    Name of License,

    Registration or License Number State of Issue Expiration Date

    Certification

    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/dd/yyyy): To (mm/dd/yyyy):

     -

    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/dd/yyyy): To (mm/dd/yyyy):

     -

    Complete Address and phone number: Last Weekly Pay $

Your Title: Hours/Week:

Number & Titles of Employees You Supervised: Supervisor’s Name & Title:

Duties:

     Page 3 of 9 PER 1 - 12/08

    Employer #3 From (mm/dd/yyyy): To (mm/dd/yyyy):

     -

    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/dd/yyyy): To (mm/dd/yyyy):

     -

    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/dd/yyyy): To (mm/dd/yyyy):

     -

    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/dd/yyyy): To (mm/dd/yyyy):

     -

    Complete Address and phone number: Last Weekly Pay $

Your Title: Hours/Week:

    Number & Titles of Employees You Supervised: Supervisor’s Name & Title:

Duties:

     Page 4 of 9 PER 1 - 12/08

    Employer #7 From (mm/dd/yyyy): To (mm/dd/yyyy):

     -

    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/dd/yyyy): To (mm/dd/yyyy):

     -

    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/dd/yyyy): To (mm/dd/yyyy):

     -

    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/dd/yyyy): To (mm/dd/yyyy):

     -

    Complete Address and phone number: Last Weekly Pay $

Your Title: Hours/Week:

    Number & Titles of Employees You Supervised: Supervisor’s Name & Title:

Duties:

     Page 5 of 9 PER 1 - 12/08

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 any conviction(s) occurring before your 18th birthday or traffic violations not listed above.

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) 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.

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    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

     Page 6 of 9 PER 1 - 12/08

    Human Resources Use Only Date Stamp

     Closing Date Date Sent: Review Initials Date

    1 Supplemental Questions Date Due:

    2 Qualified Not Qualified

    3 Conditionally Qualified Reason 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

    Date Rater’s Name Minimum Qualifications Pass Fail

    Testing Record Results

    Hired in Classification Agency Effective Date Position Number Title

     Page 7 of 9 PER 1 - 12/08

    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 1. I have read the paragraph above and do not wish to 0. WHITE (not of Hispanic Origin): All persons having origins in provide the information. any of the original peoples of Europe, North Africa, or the Middle East. 2. Enter your date of birth 1. BLACK (not Hispanic Origin): All persons having origins in any (month) (day) (year) of the Black racial groups of Africa. 2. HISPANIC: All persons of Mexican, Puerto Rican, Cuban, 3. Enter your racial/ethnic group code number (refer to Central or South American, or other Spanish culture or origin, definitions at left) 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 4. What is your sex? A. Female B. Male origins in any of the original peoples of North America, and who maintain cultural identification through tribal affiliation or community recognition. 6. OTHER

    DEFINITIONS OF VETERANS SUBJECT TO EEO/AFFIRMATIVE ACTION REGULATIONS: PLEASE PLACE AN X IN ALL BOXES WHICH APPLY TO YOU (The requirements are different from State Veterans Preference) (refer to definitions at left) 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 5. Vietnam Era Veteran duty was performed between August 5, 1964 and July 7, 1975. DISABLED VETERAN: A person entitled to disability compensation 6. Disabled Veteran 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.

    DEFINITION FOR DISABILITY PLEASE PLACE AN X IN ALL BOXES WHICH APPLY TO YOU (refer to definitions at left) 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, 7. Have a disability as defined hearing, learning, self-care, speaking, lifting, reaching, thinking performing manual tasks, breathing, working and interacting with 8. Interview accommodations may be necessary due to a others. disability

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    Filling of Vacancies

    CAREER OPPORTUNITY BULLETINS are published by the Bureau of Human Resources to show typical duties, job requirements, geographic location, salary and availability. Bulletins are available at Maine CareerCenters and on the Internet at http://www.maine.gov/bhr/state_jobs.

    Read the bulletin pertaining to each classification before making application, as supplemental information may be required.

SEPARATE APPLICATIONS: A complete application must be submitted for each separate

    classification title/code.

SUPPLEMENTAL OR ADDITIONAL INFORMATION: Answer questions or supply additional

    information to meet requirements as stated within the bulletin.

CLOSED CLASSIFICATIONS: Application material received for closed classes or after the

    closing date will be returned.

ENVELOPES: One self-addressed, stamped envelope (legal-size, #10) must be submitted with

    each application. (Some job classifications require more than one envelope; if so, the Career Opportunity Bulletin will clearly indicate this.) STATE EMPLOYEES may use the State Inter-

    Office Mail System. Envelopes will be sealed to ensure confidentiality.

    VOLUNTEER WORK: Volunteer work is accepted towards meeting minimum entrance requirements and establishing a score through numerical evaluation of training and experience (T & E). Be sure to provide length and hours per week of assignments.

    RESUMES: The information submitted on this application will be the basis for evaluating an applicant’s training and experience. A resume may be used to supplement this information but not to replace any of the required information.

    COPIES OF THE APPLICATION: Please retain a copy of your application before it is submitted to the Bureau of Human Resources.

    PROOF: With this application, furnish required proof of military service, education, training, registration, certification or licensing. Legible duplicates of licenses, registrations, certifications,

    diplomas, transcripts and related documents are accepted.

VERIFICATION OF WORK EXPERIENCE, EDUCATION AND TRAINING: Reference checks

    will be completed by the hiring agency before selection. The agency may also verify registrations, certifications, licensing, education or training.

    HIRING INTERVIEWS: Interviews are conducted by the agency. Please bring a resume and list of references to the interview.

    REGISTER: An eligible register contains the names of all persons who have successfully completed all portions of the examination for the particular classification.

UNCLASSIFIED EMPLOYEES: Unclassified employees are treated as non-state employees for

    selection purposes in the classified service.

PROBATION PERIOD: All employees must complete at least a six-month probation period.

    This is part of the selection process.

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