Name

Street Address

Street Address 2

City

State

Zip

Telephone

Email Address

Referred by

Date you are available to work

Are You Legally Eligible to Work in the U.S.? Are You Legally Eligible to Work in the U.S.? Yes No

Are you willing to take a drug test? Are you willing to take a drug test? Yes No

Are you willing to submit to a Maine background check? Are you willing to submit to a Maine background check? Yes No

Do you have a valid driver's license? Do you have a valid driver's license? Yes No

How Many Hours Do You Want to Work Per Week? How Many Hours Do You Want to Work Per Week? 0-10 10-20 20-30 30-40

What Days Are You Most Interested in Working? What Days Are You Most Interested in Working? Weekdays Weekend

Please Describe Any Work Experience

Employer's Name (Most current)

Position Held

Supervisor's Name

Employer Telephone

Reason for Departure

Duties

Start Date

End Date

May we contact this employer? May we contact this employer? Yes No

If no, Reason why not?

2nd Employer's Name

Position Held

Supervisor's Name

Employer Telephone

Reason for Departure

Duties

Start Date

End Date

May we contact this employer? May we contact this employer? Yes No

If no, Reason why not?

2nd Employer's Name

Position Held

Supervisor's Name

Employer Telephone

Reason for Departure

Duties

Start Date

End Date

May we contact this employer? May we contact this employer? Yes No

If no, Reason why not?

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