Employment Application Hand of Mercy Health Care Employment Application "*" indicates required fields Step 1 of 3 33% { Main Office: 30 Blueberry Rd, Portland, ME 04102 } Tel: (207) 747-5226 Fax: (207) 810-2016 [email protected] www.homhealthcare.org Name* First Last Today's Date* MM slash DD slash YYYY Phone*Email* Address* Street Address City State / Province / Region ZIP / Postal Code Position Applying For*Case ManagerTargeted Case ManagerOutpatient TherapistHR & Billing AssistantAdministrative AssistantReceptionistClinical SupervisorInternshipOtherIf other, type it here or "N/A"*Job Location*Portland, MEAugusta, MELewiston, MEConsent* I consent to the below:I read and understand that this job requires mandatory job shadowing prior to accepting applicants. If you are willing to participate in a job shadowing prior to accepting this position, please type your name below. If you do not accept that type decline below:Type your name below if you agree to the above statement, if not type "decline "* Are you legally eligible to work in the US?* Yes No Are you a veteran?* Yes No Do you consent to a background check?* Yes No Have you ever been convicted of a felony?* Yes No May we contact your current employer?* Yes No If no, please explain why? or N/A*Do you know anyone who works for us?* Yes No If yes, what's their name?Have you worked or applied with us before?* Yes No If yes, when? MM slash DD slash YYYY How did you hear about us?* Who is your current or last employer?*Your current or last supervisor/manager name* First Last What is your current role and title?*Notice: type “None” if you currently unemployed.Current or last employer Email* Current or last employer Phone*Why are you resigning from your current job?*Notice: type “None” if you currently unemployed.If hired, what date available to start?* MM slash DD slash YYYY Reference 1* First Last Email* Phone*Relationship*Reference 2* First Last Email* Phone*Relationship*Reference 3* First Last Email* Phone*Relationship*Can we contact your references?* Yes No What's your highest level of education?* High School Some College Associate Degree Bachelor’s Degree Graduate or Professional Degree Other Prefer Not to Answer Please select all apply and all degrees you have:Please select at least one of the following qualifications* Provisional MHRT/C Full MHRT/C Expired MHRT/C LMSW-CC LMSW LCPC-CC LCPC LCSW-CC LCSW LMFT-CC LMFT Other Prefer not to answer None of the above Please select all applyWhat is your major/s?*Please type your first major above, it must be your highest level of education.Second major, if any:Please type your second major above, if you don’t have one, please type “None”What's your highest education school's name?*Upload Resume* Drop files here or Select files Max. file size: 1 GB, Max. files: 3. Message or Comment "Optional"I certify that the facts set forth in this Application for Employment are true and complete to the best of my knowledge. I understand that if I am employed, false statements, omissions or misrepresentations may result in my dismissal. I authorize the Hand of Mercy “HOM” to make an investigation of any of the facts set forth in this application and release the HOM from any liability. HOM may contact any listed references on this application.I acknowledge and understand that the company is an “at will” employer. Therefore, any employee (regular, temporary, or other type of category employee) may resign at any time, just as the employer may terminate the employment relationship with any employee at any time, with or without cause, with or without notice to the other party.Consent* NameThis field is for validation purposes and should be left unchanged.
