Fillable Printable State of Maine Employment Application
Fillable Printable State of Maine Employment Application
State of Maine Employment Application
State of Maine
(An Equal Opportunity Employer)
Employment Application
(revised February 2015)
Last Name
First Name
M.I.
Social Security 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? (enter below)
Name #1
Name #2
Name #3
Name #4
Mailing Address
Town
State
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
http://www.maine.gov/bhr/rules_policies/policy_manual/5_1.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 a present or former Maine State employee? Yes No (If yes, provide last Department
worked)
Department
Job Title
Begin Date
End Date
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
Are you willing to work: Saturdays Sundays Holidays
Are you willing to work overtime? Yes No What shifts are you willing to work? 1
st
2
nd
3
rd
FOREIGN LANGUAGE SKILLS
Language
Speak
Read
Write
Language
Speak
Read
Write
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.
F = Full Time P = Part Time T = Temporary/Acting 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
1
0
Presque Isle
31
Thomaston
53
Bucks Harbor
DCF
1
1
Van Buren
32
Lincoln
54
Calais
1
2
Cumberland
33
Boothbay
55
Eastport
1
3
Portland
34
Oxford
56
Machias
1
4
Brunswick
35
Norway
57
York
1
6
South Portland
36
Rumford
58
Biddeford
1
7
Windham MCC
37
Penobscot
59
Kittery
1
8
Franklin
38
Bangor
60
Saco
1
9
Farmington
39
Bangor DDPC
61
Sanford
2
0
Rangeley
40
Charleston
41
Millinocket
Education
Last Yr
Completed
Name and Location
Sem
Hrs
Qtr
Hrs
Major
Minor
Yr
Of
Deg
Degre
e Type
High School
Leave
Blank
College or
University
Grad School
Prof School
Other
Professional Licenses, Certifications and Registrations
Name of License,
Registration or
Certification
License Number
State of Issue
Expiration Date
Important Instructions for Completing Employment History
In order 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 related work
history, including part-time, temporary and volunteer jobs. Be thorough and specific in the detailing of
duties. Incomplete applications may not be processed.
Current or Most Recent Employer
From (mm/dd/yyyy) -To- (mm/dd/yyyy):
-
Complete Address & 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 & Phone Number
Last Weekly Pay $
Your Title
Hours/Week
Number & Titles of Employees You Supervised
Supervisor’s Name & Title
Duties
Reason for Leaving
Employer #3
From (mm/dd/yyyy) -To- (mm/dd/yyyy):
-
Complete Address & Phone Number
Last Weekly Pay $
Your Title
Hours/Week
Number & Titles of Employees You Supervised
Supervisor’s Name & Title
Duties
Reason for Leaving
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:
Reason for Leaving:
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:
Reason for Leaving:
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:
Reason for Leaving:
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 here any juvenile
adjudications or traffic violations not listed above. Some positions require disclosure of juvenile
adjudications. Applicants for these positions will be required to disclose juvenile adjudications on a
supplemental form provided for that purpose.
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) or adjudication(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.
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, tax clearance
check, fingerprinting 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
AGENCY PERSONNEL USE ONLY
Minimum Qualifications Pass Fail
Date
Rater’s Name
Testing Record
Results
Notes/Comments
Hired in Classification Title
Agency
Effective Date
Position Number
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
0. WHITE (not of Hispanic Origin): All persons having origins in any
of the original peoples of Europe, North Africa, or the Middle East.
1. BLACK (not Hispanic Origin): All persons having origins in any of
the Black racial groups of Africa.
2. HISPANIC: All persons of Mexican, Puerto Rican, Cuban, Central
or South American, or other Spanish culture or origin, 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
origins in any of the original peoples of North America, and who
maintain cultural identification through tribal affiliation or
community recognition.
6. OTHER
1. I have read the paragraph above and do not wish to
provide the information.
2. Enter your date of birth
(month) (day) (year)
3. Enter your racial/ethnic group code number (refer to
definitions at left)
4. What is your sex? A. Female B. Male
DEFINITIONS OF VETERANS SUBJECT TO
EEO/AFFIRMATIVE ACTION REGULATIONS:
(The requirements are different from State Veterans Preference)
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
duty was performed between August 5, 1964 and July 7, 1975.
DISABLED VETERAN: A person entitled to disability compensation
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.
PLEASE PLACE AN X IN ALL BOXES WHICH APPLY
TO YOU (refer to definitions at left)
5. Vietnam Era Veteran
6. Disabled Veteran
DEFINITION FOR DISABILITY
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,
hearing, learning, self-care, speaking, lifting, reaching, thinking
performing manual tasks, breathing, working and interacting with
others.
PLEASE PLACE AN X IN ALL BOXES WHICH APPLY
TO YOU (refer to definitions at left)
7. Have a disability as defined
8. Interview accommodations may be necessary due to a
disability
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.
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.
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.
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.
