MBHA Application

Merrymeeting Behavioral Health Associates, Inc.
Application for In-Home Support Worker, BS1

Name(last) (First) (Middle) E-Mail Address
Mailing Address City State Zip Code
Telephone Numbers Work: Home: Cell:
Position Applied For: Date of Application:
How did you hear about this job opening? ____ Career center ____ Jobs In Maine web site ____ Newspaper ad. Which newspaper? _____Other. Please tell us where:
Are you currently employed?	Yes	No
May we contact your current employer?	Yes	No
How far from your home would you be willing to travel for work?
On what date would you be able to start work?
Have you been convicted of a felony in the last 10 years? If yes, please explain. Conviction will not necessarily disqualify an applicant from employment.	Yes	No
Have you been convicted of OUI (operating a vehicle while under the influence of alcohol or drugs) within the past three years? Conviction will not necessarily disqualify an applicant from employment.	Yes	No
Have you ever filed an application with us before?	Yes	No
Are you prevented from lawfully becoming employed in this country because of visa or immigration status? Proof of citizenship and/or immigration status will be required upon employment.	Yes	No
Merrymeeting Behavioral Health Associates is an Equal Opportunity Employer. We consider all applicants for all positions without regard to race, creed, religion, gender, age, disability, sexual orientation, national origin, marital or veteran status, or any other legally protected status. Corrective action will be taken in the event that discrimination is found to have occurred.
________________________________________________________ Applicants can be employed by MBHA only after clearance by the Dept. of Motor Vehicles, a criminal history check, and clearance from DHHS Child Protective Services. MBHA takes responsibility for having these checks done. ___________________________________________________

Education and Training

	Name and Town	Course of Study	Years Completed	Diploma/ Degree
Elementary School
High School
College
Other (Please Specify)

Past Employment, most recent first

Last Position Held: Responsibilities:
Organization's Name:	Employed From: To:
Address:	Wages Earned: $ per
Supervisor's Name & Title:	Phone:
May we contact this employer for a reference? Yes ____ No _____	Reason for Leaving:

Last Position Held: Responsibilities:
Organization's Name:	Employed From: To:
Address:	Wages Earned: $ per
Supervisor's Name & Title:	Phone:
May we contact this employer for a reference? Yes ____ No _____	Reason for Leaving:

Last Position Held: Responsibilities:
Organization's Name:	Employed From: To:
Address:	Wages Earned: $ per
Supervisor's Name & Title:	Phone:
May we contact this employer for a reference? Yes ____ No _____	Reason for Leaving:

Last Position Held: Responsibilities:
Organization's Name:	Employed From: To:
Address:	Wages Earned: $ per
Supervisor's Name & Title:	Phone:
May we contact this employer for a reference? Yes ____ No _____	Reason for Leaving:

If you need additional space, please continue on the back or on a separate sheet of paper.

Other Qualifications

Summarize special job-related skills and qualifications acquired from employment or other experiences.

This position requires one year of experience with children. This can be paid work, volunteer work, raising your own children, or helping with a relative's children. If this information is not included in your list of past employment, please give it here.

State any additional information you feel may be helpful to us in considering your application.

Applicant's Statement

I certify that the answers given in this application are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

In the event of employment, I understand that false or misleading information given in my application or interview/s may result in discharge. I understand also that I am required to abide by all rules and regulations of the employer if I am hired.

____________________________________________
Signature of Applicant

____________________________________________
Date

Please Return to:

Merrymeeting Behavioral Health Associates

14 Maine Street, Box 9

Brunswick , ME 04011

Phone 207-721-0214 Fax 207-721-0215 Email mbha2@midmaine.com

RELEASE AUTHORIZATION

APPLICANT COMPLETE THE FOLLOWING

I. In connection with my application for employment, I understand that a consumer report or an investigative consumer report may be requested that will include information as to my character, work habits, performance, and experience, along with reasons for termination of past employment. I understand that as directed by company policy and consistent with the job described, you may be requesting information from public and private sources about my: workers' compensation injuries, driving record, court record, education, credentials, and references.

If company policy requires, I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment.

II. Medical and workers' compensation information will only be requested in compliance with the Federal Americans with Disabilities Act (ADA) and/or any other applicable state laws. According to the Fair Credit Reporting Act, I am entitled to know if employment is denied because of information obtained by my prospective employer from a consumer reporting agency. If so, I will be notified and given the name and address of the agency or the source which provided the information.

III . I acknowledge that a telephonic facsimile (FAX) or photographic copy shall be as valid as the original. This release is valid for most federal, state and county agencies.

IV. I hereby authorize, without reservation, any law enforcement agency, institution, information service bureau, school, employer, reference or insurance company contacted by Merrymeeting Behavioral Health Associates or its agent, to furnish the information described in Section 1.

The following information is required by law enforcement agencies and other entities for positive identification purposes when checking public records. It is confidential and will not be used for any other purposes. I hereby release the employer and agents and all persons, agencies, and entities providing information or reports about me from any and all liability arising out of the requests for or release of any of the above mentioned information or reports.

Please print

Last name First name Middle

Other names you have used

Home Address

City State Zip Code

Social Security Number Date of Birth

Driver's License Number State Issuing License

Name as it appears on license

Signature Today's Date