Employment ApplicationHand of Mercy Health Care Employment Application Main Office: 1087 Forest Ave Portland, ME 04103 Tel: (207) 747-5226 Fax (207) 835-6008 info@homhealthcare.org www.homhealthcare.org Please Complete The Following QuestionsStep 1 of 333%Name* First Last Birthdate* MM slash DD slash YYYY Gender*MaleFemaleOtherIf other, what do you identify yourself? If identified above type "N/A"*Email* Phone*Address* Street Address City State / Province / Region ZIP / Postal Code Position Applying For*Case ManagerTargeted Case ManagerOutpatient TherapistOtherIf other, what's the position you are applying for? If identified above type "N/A"*Job Location*PortlandAugustaAre you legally eligible to work in the US?* Yes NoAre you a veteran?* Yes NoIf selected for employment are you willing to submit to a background check?* Yes NoHave you ever been convicted of a felony?* Yes NoMay we contact your present employer?* Yes NoIf no, please explain why?*Do you know anyone who works for us?* Yes NoIf yes, what's their name and contact information?Have you worked for us before? Or have you appliyed for this postion before?* Yes NoIf yes, when? MM slash DD slash YYYY How did you hear about us?*Who is your current employer?*Your current supervisor or manager name* First Last Phone*Email* Why are you resigning from your current job?*If hired, what date are you available to start work?* MM slash DD slash YYYY Refrences 1* First Last Phone*Email* Relationship*Refrences 2* First Last Phone*Email* Relationship*Refrences 3* First Last Phone*Email* Relationship*Can we contact your references?* Yes NoWhat's your highest level of education?*GEDHigh SchoolAssociate DegreeSome CollegeBachelor's DegreeGraduate or Professional DegreeOtherPrefer Not to AnswerWhat's the school name?*Upload Resume* Drop files here or Select filesMax. file size: 100 MB, Max. files: 3.Message or CommentConsent* 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 Employer to make an investigation of any of the facts set forth in this application and release the Employer from any liability. The employer 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.NameThis field is for validation purposes and should be left unchanged.
