Assistance Plus - Home-based Healthcare services,Professional Staffing Services, Case management, Longterm Care, behavioral and outpatient therapy services Application

ASSISTANCE PLUS MEETING YOUR GROWING NEEDS
A Professional Organization of Dedicated Health Care Providers
Application for Employment
Assistance Plus is an equal opportunity employer. It is our policy to consider all applicants without discrimination because of race, creed, color, sex, age, national origin, physical or mental disability, or any other factor not directly related to the normal requirements of the position.

Employees of Assistance Plus are employees-at-will. Thus, Assistance Plus reserves the right to terminate an employee with or without cause, with or without notice, at any time, just as the employee has the same rights.

The job offer is conditional on passing a preplacement screening prior to the first day of employment to establish the applicant can perform the essential functions of the job with or without reasonable accomodations.

If your credentials match a clients needs, you may be contacted for an interview. If no matching position is currently available, your application may be reconsidered within a one-year time frame. We would like to thank you for your interest in our company. Your application will be given serious consideration.

Please fill in this form and press the SUBMIT button at the bottom when completed or you may download the .PDF version, print and send via US mail.

Last Name:
First Name
Middle Initial
Address
City
State/Province
ZIP Code/Postal Code
Phone
Email

Position Desired:
HOMECARE SERVICES: BEHAVIORAL HEALTH SERVICES : OFFICE : PROFESSIONAL STAFFING (Long Term Care Facilities) :
Hours Available (First Choice)
Hours Available (Second Choice)
Applying For	Full time Part time
Total hours available per week:
Earliest start date:

Are you over 18 years of age? (If not, employment is subject to verification that you are of a minimum legal age and able to supply required work permit.)
Are you legally eligible for employment in the United States? (U.S. law requires that, if hired, you must furnish verification documents within 72 hours of starting work.)

Have you ever worked or applied for a position at Assistance Plus before?

If yes, when:

Can you travel if the position requires it:

Yes No

Have you been convicted of a crime?
If yes, please explain:

Have you been found guilty of abusing, neglecting or mistreating clients/residents by a court of law?

Important Notice Regarding Immunizations
Important notice to all Assistance Plus applicants regarding changes in the State statute governing immunizations required for hospital/health facility personnel. If you were born after December 31, 1956 you must present documented evidence of immunization or a copy of the actual lab test indicating immunity to Rubella (German Measles) and Rubeola (old-fashioned measles). The document must be signed by the health professional that administered the vaccine. Having either disease is not sufficient evidence of immunity.

Total Immunizations Required
Except as otherwise provided by law, each Designated Healthcare Facility in the State of Maine shall require for all employees proof of immunization or documented immunity against:

Rubeola (measles)

Mumps

Rubella (German measles)

Varicella (chicken pox)

Hepatitis B * optional

Hepatitis B Series? If you have started or completed the Hepatitis B Series, please bring documentation with you to your interview appointment along with your immunization record. This will speed up the hiring process tremendously.

* There are specific rules regulating exceptions and declinations for required immunizations. More extensive information will be provided during the interview process, or if you need immediate clarification please call the human resource department at 453-4708 or toll free at 1-800-781-0070.

All health screen reports will be maintained in the strictest of confidence and do not become a part of your personnel file.

FOR ALL CNA, PCA, & PSS APPLICANTS ONLY
This is a State of Maine Registry request for verification of a certified nursing assistant.

Have you completed the Certified Nurses Aide State Registry Form?
Are you presently on the State of Maine C.N.A. Registry?

The following information will be used for the State of Maine Registry Request for Verification:
Full name
Maiden Name
Address

Have you ever had a violation reported to the State of Maine Registry concerning abuse, neglect, mistreatment of clients/residents or misappropriation of his/her property?

If yes, please explain:

R.N./L.P.N. APPLICANTS ONLY
R.N. GRADUATE: R.N. LICENSED: L.P.N. GRADUATE: L.P.N. LICENSED:

License Number: State: Expiration Date:

Have you ever been called before a licensing board or asked by a licensing board to answer a complaint?

If yes, please explain:

Has your professional license ever been subject to disciplinary action, suspended, revoked, placed on probation or voluntarily surrendered?

If yes, please explain:

EDUCATIONAL BACKGROUND

Name of High School
Address
Course of Study
Degree or Diploma
Year

Name of College/Tech/Business School
Address
Course of Study
Degree or Diploma
Year

Name of Graduate School
Address
Course of Study
Degree or Diploma
Year

Continuing Education
Address
Course of Study
Degree or Diploma
Year

Long Term Goals/Plan

Other Skills/Certifications

WORK EXPERIENCE: Account for the last ten years of employment, listing your most recent employer first.

From-To / Month & Year
Employer Name, Address & Phone
Title/Duties
Reason for Leaving
Supervisor's Name
Who may we contact? Name & phone

From-To / Month & Year
Employer Name, Address & Phone
Title/Duties
Reason for Leaving
Supervisor's Name
Who may we contact? Name & phone

From-To / Month & Year
Employer Name, Address & Phone
Title/Duties
Reason for Leaving
Supervisor's Name
Who may we contact? Name & phone

From-To / Month & Year
Employer Name, Address & Phone
Title/Duties
Reason for Leaving
Supervisor's Name
Who may we contact? Name & phone

REFERENCES: List 3 professional references. References should be persons other than relatives.

Name
Address
Relationship
Telephone

Name
Address
Relationship
Telephone

Name
Address
Relationship
Telephone

The information provided in this Application is true, correct and complete. If employed, any misrepresentation or omission of fact may result in my dismissal.

I understand that acceptance of an offer of employment does not create a contractual obligation upon the employer to continue to employ me in the future.

My application will be considered active for twelve months. For consideration after that, I understand that I must reapply.

I authorize my present/former employer(s) to release employment information to Assistance Plus regarding my performance.