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jobapplication

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Name *

First

Middle

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Email

Confirm Email

Home Phone *

Cell Phone *

I'm authorized to work in the United States *

Yes
No

Expected Salary *

Do you have a Driver's License? *

Yes
No

On what date can you start? *

Are you available to work? *

Full-Time
Part-Time
Full-Time Temporary

States for any employer? *

If needed, can you travel for work? *

Yes
No

Please check which days and shifts you are available to work:

DAY OF THE WEEK *

8:00 AM TO 8:00 PM FIRST SHIFT *

8:00 PM TO 8:00 AM SECOND SHIFT *

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Emergency Contact Names: *

Relationship? *

Emergency Contact Number: *

Do you have any reason why you can not perform the essential functions of the job for which you are applying with or without reasonable accommodation? *

Yes
No

Have you ever used name other than the one listed above? *

Yes
No
If Yes, Please list here

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Have you even been convicted of a crime? *

Yes
No
If Yes, Explain and include dates:

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Have you ever had a substantiated case brought against you by child and/or adult protective services?? *

Yes
No
If Yes, Please and include dates:

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Please List all Licenses and certifications you currently hold : *

DSP
CRMA
CPR/FIRST AID
CPI
LCSW
LCPC
MSW
LADC
CAN
LPN
RN
MHRT

OTHER:

LIST HERE

Education History

SCHOOL 1

School Name *

Location *

Course of Study *

Years of completed *

Degree or Diploma *

SCHOOL 2

School Name *

Location *

Course of Study *

Years of completed *

Degree or Diploma *

SCHOOL3

School Name *

Location *

Course of Study *

Years of completed *

Degree or Diploma *

SCHOOL 4

School Name *

Location *

Course of Study *

Years of completed *

Degree or Diploma *

EMPLOYMENT HISTORY

Employer 1

Company/Agency Name *

Telephone *

Address *

Employment Dates *

From:

To

Job Title *

Weekly Pay *

Supervisor *

Reason for Leaving *

May we contact this employer *

Yes
No

Telephone *

If No, Please Explain Why? *

Employer 2

Company/ Agency Name *

Job Title *

Address *

Employment Dates *

From:

Supervisor *

To:

May we contact this Employer *

Yes
No

Weekly Pay *

If No, Please Explain Why?: *

Reason for Leaving *

Military History *

Did you serve in the US Armed Forces *

Yes
No

If Yes, Which Branch? *

Describe any military training you received that you believe would be pertinent to the position for which you are applying for. *

REFERENCES

Name *

Telephone/ Email address *

Single Line Text *

Telephone/ Email address (copy) *

Single Line Text (copy) *

Telephone/ Email address (copy) (copy) *

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Telephone/ Email address (copy) (copy) *

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Telephone/ Email address (copy) (copy) *

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Telephone/ Email address (copy) (copy) *

LIGHTHOUSE HEALTH SERVICES

EQUAL OPPORTUNITY EMPLOYER

Lighthouse Health Services is an equal opportunity employer and does not discriminate against employees or job applicants based on race, religion, color, sex, age, national origin, mental and physical disability, veteran or family status, genetic information, or any other status or condition protected by applicable federal, state, or local laws, except where a bona fide occupational qualification applies.

BACKGROUND CHECK INFORMATION

Lighthouse Health Services receives background information on all their employees from the State Bureau of Investigation, State of Maine Department of Health & Human Services Child Protective Services; and the State of Maine Bureau of Motor Vehicles. If, I (candidate) have lived in states other than Maine, I further authorize Lighthouse Health Services to complete appropriate out of state background checks. Applicants should understand that any information that may be listed on these checks that relate to incidents in the applicant’s past, affecting their relationship with the consumers/clients in the program, the staff, or the operation of the program, may be considered a sufficient reason to reject their application for employment or could mean their immediate termination.

The information I have provided in this application for employment is true, correct, and complete. I understand my application will be rejected if false, incomplete, omitted, or misrepresented information is discovered and I may be terminated, if after I am employed, it is discovered.

I authorize Lighthouse Health Services to contact and obtain information from previous employers, educational institutions, and “references” I provided, and any other party necessary to verify the accuracy of information I disclosed in this application, a related employment resume or a personal interview. This application is not an employment agreement. If I accept an offer of employment from Lighthouse Health Services, I understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with Lighthouse Health Services is of an “at will” nature. My employment is at the will of the employer, and either Lighthouse Health Services or I may at any time terminate the employment relationship with or without cause and without prior notice, unless required by law. I understand that no one other than the CEO of Lighthouse Health Services or appointed delegate, has the authority to enter into any employment agreement with terms contrary to the foregoing and then only in writing signed by the CEO or delegate.

I fully understand and accept all terms and conditions of the above statement

APPLICANT’S SIGNATURE_______________________DATE_______________________

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Additional Information *

At Lighthouse, caring is our calling, our motto describes well what we are calling for. We are dedicated to being that light that brings hope into people’s lives.

Contact

158 Court Street Suite 13
Auburn, ME 04210

Phone: +1 207-705-2095

info@lhhs-maine.com

Office hours

Monday-Friday 9am -5pm.

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