Penobscot Community Health Care
207-404-8000 | www.pchc.com
All applicants for employment will be considered without regard to age, race, color, religion, gender, national origin, marital status, veteran status, sexual orientation, personal or group characteristic, or physical or mental disability. We offer reasonable accommodations to qualified disabled persons. No question on this application is intended to secure information to be used for unlawful purposes.
First Name *
Last Name *
Address *
Home Phone *
Business or Message Phone
Email Address *
Position(s) Desired *
Full Time Part Time
Are you authorized to work in the U.S. on an unrestricted basis? *
Yes No
Date Available *
Hours Available *
Are there any hours, shifts, or days you cannot or will not work?
Agency or Individual Referral (if applicable)
Have you ever worked at PCHC before? *
Are you legally authorized to work in the United States? *
Have you ever been convicted of any crime other than a minor traffic violation? (Conviction will not necessarily disqualify an appilcant for employment.) *
If yes, please explain.
School Name *
Major or Focus
Address of School *
Years Completed *
Degree
School Name
Address of School
Years Completed
Please provide information for the past your past 5 years of employment. If you require more space, please include any additional information with your resumé.
Employer Name and Address *
Start Date: *
End Date: *
Beginning Salary *
Ending Salary *
Title/Duties *
Employer Phone Number: *
Supervisor's Name / Title *
Supervisor's Phone *
Reason for Leaving *
Employer Name and Address
Start Date:
End Date:
Beginning Salary
Ending Salary
Title/Duties
Employer Phone Number:
Supervisor's Name / Title
Supervisor's Phone
Reason for Leaving
Please list 3 professional references, excluding relatives who could attest to your good character and work history.
Reference Name *
Reference Phone *
Reference Address *
Years Acquainted *
Position/Business *
I certify that all of the statements contained in this application are true and complete. I hereby authorize PCHC (Penobscot Community Health Care) to investigate all statements contained in my application and to contact my former employers.
If I am a finalist, PCHC has my permission to contact my current employer. I understand that any false statements, omissions or misrepresentations will constitute sufficient cause and reason for either refusal to hire or termination from employment.
I understand that, unless otherwise expressly agreed to in writing, signed by a duly authorized official of Penobscot Community Health Care, if employed by Penobscot Community Health Care, my employment will be at will and without fixed term, and that either of us may terminate the employment relationship at any time with or without prior notice and with or without cause.
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Date * Attach Resume:
Fields marked with * are required.
