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OHI Employment Application

Name(*)
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Telephone(*)
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Cell Phone(*)
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Email Address(*)
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Mailing Address(*)
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City(*)
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State(*)
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Zip(*)
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Can we correspond with you via email?(*)
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Have you ever applied for employment with us?(*)
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If yes, when?(*)
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Have you ever worked for us before?(*)
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If yes, when?(*)
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Are you legally eligible for employment in the United States?(*)
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Do you have any relatives employed at OHI?(*)
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If yes, who?(*)
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List any other names under which you have been employed(*)
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List all other states in which you have lived or worked(*)
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Position Desired(*)

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List Other:(*)
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How did you hear about a position at OHI?(*)

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List Other:(*)
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Availability: Check ALL you would be available and willing to work(*)

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Education
High School
Name/Location of School(*)
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Course of Study(*)
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# of Years Completed(*)
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Did you Graduate?(*)
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Diploma/Degree(*)
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College
Name/Location of School
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Course of Study
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# of Years Completed
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Did you Graduate?
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Diploma/Degree
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Other
Name/Location of School
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Course of Study
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# of Years Completed
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Did you Graduate?
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Diploma/Degree
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CERTIFICATIONS / TRAINING / EXPERIENCE

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MEMBERSHIP IN PROFESSIONAL OR CIVIC ORGANIZATIONS (Exclude those which may disclose your race, color, sex, sexual orientation, age, religion, national origin, disability or veterans status)
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EMPLOYMENT ELIGIBILITY CHECKS
Have you ever been convicted of any crime or pled guilty, NOLO or no contest?
Answering ”Yes” to this question will not necessarily disqualify an applicant from employment. Please disclose convictions that occurred outside the State of Maine. If you have any questions about whether or not you have been convicted of a crime, pled guilty, NOLO or no contest, please write in your questions below.(*)
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If you answer YES, please list the approximate date, nature of offense, location, status and penalty:(*)
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Is there a criminal action currently pending against you?
Answering ”Yes” to this question will not necessarily disqualify an applicant from employment. Please disclose criminal action that occurred outside the State of Maine. If you have any questions about whether or not you have any criminal action currently pending against you, please write in your questions below.(*)
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If you answer YES, please list the approximate date, nature of offense, location, and status:(*)
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Please list any motor vehicle violations or records you have received in your history as a driver. Please include out-of-state violations.
Please note, most positions require your ability to drive a vehicle. According to OHI’s Driver Selection Policy, even violations many years old may impact on your ability to drive for OHI. Please let us know if you desire to review the policy.(*)

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If other, please list any other items that would be listed on your Driving Record Report. If you have any question about whether or not an item would be listed on your Driving Record Report, please disclose the item.(*)
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Do you have a prior employment history of or have you ever been investigated for child abuse; abuse to individuals with disabilities or the elderly?(*)
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If you answer YES, please list the approximate date, nature of offense, location, status and penalty:(*)
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Have you ever been substantiated for abuse, neglect or exploitation by the State of Maine Adult Protective Services and/or the Department of Health and Human Services against an adult with intellectual disabilities, autism or mental illness?(*)
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If you answer YES, please list the approximate date, nature of offense, location, status and penalty:(*)
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MISCELLANEOUS ELIGIBILITY QUESTIONS:
Have you had a valid drivers license for more than three consecutive years? If no, explain.(*)
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If no, explain(*)
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Do you have a valid State of Maine Driver’s License?(*)
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If no, explain(*)
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Do you have current motor vehicle insurance, vehicle registration and vehicle inspection sticker?(*)
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Have you ever been under investigation or been issued any formal or informal performance improvement plans or disciplinary actions by a previous employer?(*)
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If yes, explain(*)
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Are you now or have you ever been excluded from participating in Medicaid and/or Medicare?(*)
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If yes, explain. Provide reinstatement letter if exclusion has expired.(*)
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I authorize OHI to complete employment eligibility checks for criminal, FBI, motor vehicle, child and adult protective and other areas. I understand eligibility checks occur prior to and/or post job offer. I have read and understand the above questions. I understand I can speak with a representative from Human Resources if I have any questions regarding this form. I understand that prior convictions of crimes, driving record entries and child or adult protective histories may stay on my record indefinitely.
Signature/Date(*)
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EMPLOYMENT HISTORY

OHI requires all applicants complete the Employment History section of this Application for Employment EVEN IF YOU HAVE PROVIDED US WITH A RESUME. Start with present or most recent employer. Please account for ALL employment in chronological order, no matter how short in duration. Please assure you provide current telephone numbers and names of supervisors and contact persons.
Employer 1
Company Name(*)
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Telephone(*)
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Address(*)
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Name of Supervisor(*)
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Employed (state month and year) From(*)
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Employed (state month and year) To(*)
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Job Title and Description of Responsibilities:(*)
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Reason for Leaving(*)
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Employer 2
Company Name
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Telephone
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Address
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Name of Supervisor
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Employed (state month and year) From
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Employed (state month and year) To
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Job Title and Description of Responsibilities:
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Reason for Leaving
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Employer 3
Company Name
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Telephone
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Address
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Name of Supervisor
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Employed (state month and year) From
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Employed (state month and year) To
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Job Title and Description of Responsibilities:
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Reason for Leaving
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Employer 4
Company Name
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Telephone
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Address
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Name of Supervisor
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Employed (state month and year) From
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Employed (state month and year) To
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Job Title and Description of Responsibilities:
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Reason for Leaving
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If you need more space than the 4 employers above, fill in each additional employer here
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YOUR SIGNATURE INDICATES WE MAY CONTACT THE EMPLOYERS LISTED ABOVE, UNLESS YOU INDICATE THOSE YOU DO NOT WANT US TO CONTACT.
Do not contact employer #:
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Reason:
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Do not contact employer #:
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Reason:
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Applicant Signature/Date(*)
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REFERENCES

List two (2) professional and one (1) personal reference we may contact. Please do not include former employers.
Reference 1
Name(*)
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Telephone(*)
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Relationship(*)
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Street(*)
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City(*)
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State(*)
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Zip(*)
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Email(*)
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Reference 2
Name(*)
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Telephone(*)
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Relationship(*)
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Street(*)
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City(*)
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State(*)
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Zip(*)
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Email(*)
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Reference 3
Name(*)
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Telephone(*)
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Relationship(*)
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Street(*)
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City(*)
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State(*)
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Zip(*)
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Email(*)
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PARTIAL CONDITIONS OF EMPLOYMENT

I UNDERSTAND AND AGREE THAT:

It is my understanding that OHI may make a thorough review of my experience and education and may verify all application and/or oral interview materials. I authorize such review and the giving and receiving of any information requested by OHI. I release from liability any person giving or receiving such information. Falsification, misrepresentation, or omission of facts so given, or other derogatory information discovered as a result of this review may prevent my being hired, or if hired, may subject me to immediate dismissal.

Although OHI makes every effort to accommodate employee’s preferences, the needs of persons supported by OHI may, at times, make the following conditions mandatory: overtime, shift work, holidays, a rotating schedule, and/or a work schedule or location other than for which I may have been hired. I understand and accept these conditions of my future or continuing employment. I further understand that if I am employed, I am employed for an indefinite period of time (at-will) and OHI may change wages, benefits, and conditions of my employment at any time.

In consideration for my employment and my being considered for employment by OHI, I agree to follow the policies, rules, practices, trainings and regulations of OHI, and acknowledge that these policies, rules, practices, and regulations may be changed, interpreted, withdrawn, or added to by OHI, at any time, at its discretion, and without any prior notice to me. I further acknowledge that my employment may be ended, and any offer of employment, if such is made, may be withdrawn, with or without prior notice, at any time, for any reason at the option of myself or OHI. I will notify OHI of any future arrest, summons or conviction of any crime while this application is pending.

I understand that representatives of OHI do not have the authority to enter into any agreement for employment for any specified period of time. Further, no representative of OHI may guarantee other personnel moves either prior to commencement of employment or after I have become employed. Assurances of any benefits or terms and conditions of employment, or any agreement contrary to the foregoing, may not be entered into.

OHI reserves the right due to policies, procedures, regulations and state and federal laws to complete criminal record, FBI checks, child protective, motor vehicle, and other eligibility for employment checks on all applications and employees. I understand and am willing as part of my position at OHI, to use my personal vehicle to transport people with disabilities to activities in the community and for other reasons.

I understand that the position I am applying for may involve implementing crisis prevention and intervention services which may include lifting up to ¼ of my body weight and guiding persons with disabilities against potential resistance. I understand this as a condition of employment and have no reason to believe I cannot implement these or other responsibilities of the position for which I am applying with or without reasonable accommodation.

I understand that my application will remain active until a hiring decision is made. I have read, had the opportunity to ask questions, and understand the above. My signature acknowledges that the answers I have provided are true and complete.
Applicant Signature/Date(*)
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Prospective employees shall receive consideration without discrimination because of age, race, color, sex, sexual orientation, religion, national origin, disability, genetic information, and/or Veteran’s status.
 
EMPLOYMENT ELIGIBILITY DISCLOSURE AND AUTHORIZATION

I authorize OHI to obtain information regarding my current or past employment, and/or information from personal references. I release from liability those individuals providing such information to OHI.
Applicant Signature/Date(*)
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