Southern Maine Agency on Aging

Application For Employment

SMAA considers applicants for all positions without regard to age, race, religion, color, gender, disability, national origin, sexual preferences or any other legally protected status. If you need accommodations to fill out this form, please call Human Resources at (207-396-6500).

Position(s) Applied for:
Date of Application:
How did you hear about us? Advertisement Friend Walk-In Employment Agency Relative Other

Last Name	First Name		Middle Initial
Street Address:
City	State	Zip Code
Telephone Number:	Day-Time Evening Best Time to Call
Have you ever filed an application with SMAA before? Yes No If yes, give date(s)
Have you ever been employed by SMAA before? Yes No If yes, give job title and dates of employment
Type of Employment desired Full Time Part Time Temporary Anything Available
On what date would you be available for work?
Are you legally eligible for employment in this country? Yes No
Have you been convicted of a felony within the last 7 years? (Conviction will not necessarily disqualify an applicant from employment) Yes No If yes, please explain

Educational Background
A. List last three (3) schools attended, starting with last one
B. Indicate degree or diploma earned, if any.
C. Indicate course of study.
D. Grade Point Average.
A. School	B. Degree Diploma	C. Course of Study	D. GPA

Other Special Skills, Knowledge, or Qualifications

Employment Experience
Start with your present or last job. Include any job-related military service assignments and volunteer activities. You may exclude organizations which indicate age, race, religion, color, gender, disability, national origin, sexual preference or other protected status. Prior work history (list last or present employer first)
1. Employer	Date(s) Employed
Employer Address	Employer Telephone
Job Title	Rate of Pay
Supervisor's Name and Title
Reason for leaving
Describe in detail the work you did
May we contact the employer listed above? Yes No

2. Employer	Date(s) Employed
Employer Address	Employer Telephone
Job Title	Rate of Pay
Supervisor's Name and Title
Reason for leaving
Describe in detail the work you did
May we contact the employer listed above? Yes No

3. Employer	Date(s) Employed
Employer Address	Employer Telephone
Job Title	Rate of Pay
Supervisor's Name and Title
Reason for leaving
Describe in detail the work you did
May we contact the employer listed above? Yes No

Comments (including explanation of any gaps in employment)

Check any business machines you can operate if they relate to the position for which you are applying (indicate speed where requested)
Typewriter WPM	Calculator	Computer	Shorthand
Are you proficient in using any computer software programs? If so, please list them (i.e., Microsoft Word, Lotus, etc.)

List any relevant professional, trade, business, or civic associations and any offices held. (You may exclude memberships which would reveal age, race, religion, color, gender, disability, national origin, sexual preference or other protected status.)
Organization	Offices Held
List any relevant special accomplishments, licenses, publications, awards. (You may exclude memberships which would reveal age, race, religion, color, gender, disability, national origin, sexual preference or other protected status.)
List any additional information you would like us to consider.

References

List the name and telephone number of three business/work references who are not related to you. If not applicable, list three school or personal references who are not related to you.

Name/Organization/Title/Relationship to You

Telephone

Yrs Known

Applicant's Statement

I certify that answers given herein 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. This may include but is not limited to present and past schools and employers, references and criminal records.

I hereby understand and acknowledge that all employment at SMAA is for an indefinite period of time and is terminable at the will of the Agency or the employee, at any time, with or without notice, for any reason or for no reason. Only the Executive Director has the authority to commit the Agency to a contract of employment on any other basis, and then only in writing.

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 in the event of employment, that I would be required to abide by all rules and regulations of the Southern Maine Area Agency on Aging.

Signature of Applicant

(In lieu of a written signature, please type your name
followed by your initials, for example "Your Name - yn")

Date

This application will remain active for thirty (30) days. At the end of 30 days you must submit a new application if you wish to be considered for subsequent openings.

SMAA IS AN EQUAL OPPORTUNITY, AFFIRMATIVE ACTION, ADA COMPLIANCE EMPLOYER

- CLICK THE SUBMIT BUTTON ONLY ONCE PLEASE!!!