Name: Bucksport Regional Health Center
Price range: $$

General Information
First Name
Last Name
Middle Initial
Mailing Address
Street Address Address Line 2 City State ZIP Code
Email
Telephone #
Cellphone #
Position Applied For*

(Note: a separate application is required for each position posted)
How did you hear of the position?
Education
High School
Name
Location
Years Completed
Major Courses
Diploma/Degree/Certification
College
Name
Location
Years Completed
Major Courses
Diploma/Degree/Certification
Business or Trade School
Name
Location
Months Attended
Please enter a number greater than or equal to 0.
Major Courses
Diploma/Degree/Certification
Other Licenses or Certifications
Name
Location
Length of Program
Major Courses
Diploma/Degree/Certification

Employment History
Please list your complete employment history. List present or most recent employer first.
Employer
Employer Name
Name of Supervisor
Address
Street Address Address Line 2 City State ZIP Code
Start Date (month/year)
End Date (month/year)
Reason for leaving
Type of work performed
Employer
Employer Name
Name of Supervisor
Address
Street Address Address Line 2 City State ZIP Code
Start Date (month/year)
End Date (month/year)
Reason for leaving
Type of work performed
Employer
Employer Name
Name of Supervisor
Address
Street Address Address Line 2 City State ZIP Code
Start Date (month/year)
End Date (month/year)
Reason for leaving
Type of work performed
Employment Information
Are you presently employed?
- Yes
- No
If so, may we contact your present employer?
- Yes
- No
If you served in the United States Armed Forces, briefly list the dates, rank, and skills acquired:

Certifications, Registrations and Licenses
Certification/Registration/License
Certification, Registration or License Type
Document Number
State
Date Issued
Exp. Date
Temporary/Permanent
- Temporary
- Permanent
Certification/Registration/License
Certification, Registration or License Type
Document Number
State
Date Issued
Exp. Date
Temporary/Permanent
- Temporary
- Permanent
Certification/Registration/License
Certification, Registration or License Type
Document Number
State
Date Issued
Exp. Date
Temporary/Permanent
- Temporary
- Permanent
Certification/Registration/License
Certification, Registration or License Type
Document Number
State
Date Issued
Exp. Date
Temporary/Permanent
- Temporary
- Permanent
References (work references are preferred)
Reference
Name
How They Know You
Email
Phone
Reference
Name
How They Know You
Email
Phone
Reference
Name
How They Know You
Email
Phone
Reference
Name
How They Know You
Email
Phone
I certify that the answers given by me to the foregoing questions and statements are true and correct to the best of my knowledge without consequential omissions of any kind. I agree that the Health Center shall not be held liable in any respect if my employment is rejected or subsequently terminated because of false statements, answers or omissions made by me in this application. I understand that any misleading or incorrect statements may render this application void, and if employed, may lead to employment termination. I understand that a medical examination based on the requirements of the position for which I am being considered may be required. I also voluntarily and knowingly authorize the companies, schools or persons named above to give any information requested regarding my former employment, character and qualifications. I hereby voluntarily and knowingly fully release and discharge, absolve, indemnify, and hold harmless said companies, schools or persons from any and all liability for any damages for issuing this information, except for the malicious and willful disclosure of derogatory facts concerning my employment made for the express purpose of preventing me from obtaining employment, which the party disclosing such facts knows to be untrue. In consideration of my employment, I agree to conform to the rules and regulations of this organization. My employment and compensation can be terminated with or without cause and with or without notice, at any time, at the option of either my employer or me.
Signature
Date
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BucksportRegional Health Center

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Employment Application

Step 1 of 4

General Information

Education

High School

College

Business or Trade School

Other Licenses or Certifications

Employment History

Employer

Employer

Employer

Employment Information

Personal Information

Certifications, Registrations and Licenses

Certification/Registration/License

Certification/Registration/License

Certification/Registration/License

Certification/Registration/License

References (work references are preferred)

Reference

Reference

Reference

Reference

Bucksport Location

Hours - Bucksport

Ellsworth Location

Hours - Ellsworth