ࡱ> #` >bjbj\.\. 5>D>D"W<<<<84VVVVWl \}Y 2d2d2dJd gjl|||||||$~hz)|mf| gmm)|<<2dJdE}uuum<R2dJd|um|uu"u2dY PݘoVmuuD,}0\}umuummummmmm)|)|ummm\}mmmml l l D6Vl l l VD,4<<<<<<  Waldo County Healthcare, Inc. 118 Northport Avenue ( P.O. Box 287 ( Belfast, Maine 04915 ( (207) 338-9372 ( Fax: (207) 338-9382 APPLICATION FOR EMPLOYMENT Waldo County Healthcare, INC is an Equal Opportunity Employer Last Name First Name MI Date of Application  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT      Address City State Zip  FORMTEXT        FORMTEXT        FORMTEXT ME  FORMTEXT      Telephone E-Mail Address Social Security Number (optional)  FORMTEXT (207)  FORMTEXT        FORMTEXT      How long have you been a resident at the city above?  FORMTEXT      How long have you been a resident of this state?  FORMTEXT      Are you over the age of 18?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoPosition(s) Applied For:  FORMTEXT      Do you want to work:  FORMCHECKBOX  Full Time  FORMCHECKBOX  Part Time  FORMCHECKBOX  Per Diem (when needed) Specify Days and Hours:  FORMTEXT       If hired, on what date would you be available to work?  FORMTEXT       ( Relate any special training, experience, certifications, skills or knowledge, which you feel, may be relevant to the job you are seeking with the Organization:  FORMTEXT       ( List your hobbies:  FORMTEXT       ( Is there additional information relative to change of your name, use of an assumed name, or a nickname necessary to enable a check on your work record?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, Please explain:  FORMTEXT       How did you learn about us?  FORMCHECKBOX  Walk-in  FORMCHECKBOX  Friend  FORMCHECKBOX  Internet  FORMCHECKBOX  Waldo County Healthcare, INC Employee List his/her name:  FORMTEXT        FORMCHECKBOX  Advertisement Where did you see the ad?  FORMTEXT        FORMCHECKBOX  Employment Agency Name of Agency:  FORMTEXT        FORMCHECKBOX  College Placement Office College:  FORMTEXT        FORMCHECKBOX  Other:  FORMTEXT       PERSONAL INFORMATION Are you a relative of or married to any present Waldo County Healthcare, INC. Employee?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, state relationship and name: FORMTEXT       Have you ever been convicted of a felony or misdemeanor?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, please explain: FORMTEXT       Have you ever been or are you sanctioned by Medicare and Medicaid Programs or any other Federal Government Program?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, please explain:  FORMTEXT       In case of an emergency, notify: Name: FORMTEXT       Address: FORMTEXT       Telephone: FORMTEXT       PERSONAL INFORMATION Name and Address of SchoolCourse Of StudyCheck Last Year CompletedDiploma/Degree High School  FORMTEXT       FORMTEXT       9 10 11 12  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX  FORMTEXT       Undergraduate College  FORMTEXT       FORMTEXT       1 2 3 4  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX  FORMTEXT       Graduate Professional  FORMTEXT       FORMTEXT       1 2 3 4  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX  FORMTEXT       Other (Specify)  FORMTEXT       FORMTEXT       1 2 3 4  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX  FORMTEXT       NOTE: If you did not graduate from high school, have you obtained your high school GED?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, where and when did you obtain it?  FORMTEXT       Military Service: Branch of Service:  FORMTEXT       Rank at Discharge:  FORMTEXT       Duties: FORMTEXT       Dates of Service:  FORMTEXT       PERSONAL REFERENCES * Please do NOT list former employers or relatives here. NameComplete AddressYears KnownTelephone Number 1.  FORMTEXT       FORMTEXT        FORMTEXT        FORMTEXT (207)  2. FORMTEXT       FORMTEXT        FORMTEXT        FORMTEXT (207)  3. FORMTEXT       FORMTEXT        FORMTEXT        FORMTEXT (207)  EMPLOYMENT EXPERIENCE Please do NOT state,  See resume. 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Beginning with the most present or the most recent, list all previous. Include self-employment, summer, and part-time jobs. summer, and part-time jobs. summer, and part-time jobs. summer, and part-time jobs. summer, and part-time jobs. summer, and part-time jobs. summer, and part-time jobs. Employer  FORMTEXT       Dates Employed Work PerformedAddress  FORMTEXT       From To FORMTEXT       Telephone  FORMTEXT        FORMTEXT        FORMTEXT       FORMTEXT       Job Title  FORMTEXT       Supervisor  FORMTEXT        Hourly Rate/Salary FORMTEXT        Starting Final FORMTEXT       Reason for Leaving  FORMTEXT        FORMTEXT        FORMTEXT       FORMTEXT        Employer  FORMTEXT       Dates Employed Work PerformedAddress  FORMTEXT       From To FORMTEXT       Telephone  FORMTEXT        FORMTEXT        FORMTEXT       FORMTEXT       Job Title  FORMTEXT       Supervisor  FORMTEXT        Hourly Rate/Salary FORMTEXT        Starting Final FORMTEXT       Reason for Leaving  FORMTEXT        FORMTEXT        FORMTEXT       FORMTEXT        Employer  FORMTEXT       Dates Employed Work PerformedAddress  FORMTEXT       From To FORMTEXT       Telephone  FORMTEXT        FORMTEXT        FORMTEXT       FORMTEXT       Job Title  FORMTEXT       Supervisor  FORMTEXT        Hourly Rate/Salary FORMTEXT        Starting Final FORMTEXT       Reason for Leaving  FORMTEXT        FORMTEXT        FORMTEXT       FORMTEXT        Employer  FORMTEXT       Dates Employed Work PerformedAddress  FORMTEXT       From To FORMTEXT       Telephone  FORMTEXT        FORMTEXT        FORMTEXT       FORMTEXT       Job Title  FORMTEXT       Supervisor  FORMTEXT        Hourly Rate/Salary FORMTEXT        Starting Final FORMTEXT       Reason for Leaving  FORMTEXT        FORMTEXT        FORMTEXT       FORMTEXT        If you need additional space, please continue on a separate sheet of paper.  May we contact the employers listed:  FORMCHECKBOX  Yes  FORMCHECKBOX  No If not, indicated which one(s) you do not wish us to contact: FORMTEXT        AUTHORIZATION AND WAIVER The facts set forth in my application for employment are true and complete. I understand that if employed, false statements on this application shall be considered sufficient cause for dismissal. I voluntarily authorize Waldo County Healthcare, Inc. to make a thorough investigation of my past employment and activities and agree to cooperate in such investigation. I hereby waive written or other notice from all persons, prior employers, companies and/or corporations, police, law enforcement agencies, and educational institutions of their release of any information to Waldo County Healthcare, Inc., and release such agents from any liability to claim relating to their release of information. I also authorize Waldo County Healthcare, Inc. and/or its agents, to verify information contained on my application and to verify criminal history conviction records and motor vehicle driving records. Public Law 91-508 requires that we advise you that a routine inquiry may be made during our initial or subsequent processing which will provide applicable information including character, general reputation and personal characteristics. Release of personal and/or work references pertaining to a potential employee of this corporation is property of the corporation and is fully confidential. I understand that by accepting employment, I must successfully complete a post-offer screen required by Waldo County Healthcare, Inc. for the position for which I have applied. For purposes of the Authorization and Waiver, a photocopy of my signature shall have the same force and effect as my original signature.  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