EMPLOYMENT APPLICATION

EMPLOYMENT EXPERIENCE
(List each job held. Start with your present or last job. Include military service assignments and volunteer activities.)
Date From
Month
Day
Year
Date To
Month
Day
Year
Employer Name
Employer Address
Employer's Phone Number
Job Title
Starting Salary/Hourly Rate
Final Salary/Hourly Rate
Supervisor
Reason for Leaving
Work Performed
May we contact?
- Yes
- No
Are you known by another name?
- Yes
- No
If yes, What name?
EMPLOYMENT GAPS
PLEASE EXPLAIN GAPS IN EMPLOYMENT GREATER THAN 90 DAYS
Dates
Reason

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REFERENCES
(List professional references only. Do not list friends or relatives.)
Name
Title & Place of Employement
Phone Number
Are you known to schools by another name?
- Yes
- No
If Yes, what name(s) are you known by?

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PRE-EMPLOYMENT STATEMENT
Consent*
I represent that my responses set forth in this application are truthful, accurate, and complete. Any and all false or inaccurate statements made by me in this Application or otherwise during the employment evaluation process shall be grounds both for rejecting my Application for employment and, should I be hired by Health Access Network (HAN), termination of my employment.

I authorize representatives of HAN to contact educational institutions, state and federal agencies (to conduct criminal history records checks) and employers designated in this Application for purposes of verification and investigation of my educational, criminal record, and employment background and performance. Such individuals and organizations are authorized to release such information as may be requested by a HAN representative. I hereby release all such persons from liability or damages incurred as a result of furnishing such information. I understand that an unsatisfactory reference shall be grounds both for rejecting my Application for employment and, should I be hired by HAN, termination of my employment. Should I be employed by HAN, I understand that I could be subject to an outside probe if accused of wrongdoing.

Please be aware that HAN is required to report new hire information to the State of Maine, Department of Human Services, Division of Support Enforcement and Recovery weekly or within 7 days of the date of hire. HAN complies with this legal requirement.

I certify that I am neither suspended nor excluded from participation in Medicare health programs under provisions of sections 1128 or 1156 of the Social Security Act.

Submission of the application does not entitle me to be interviewed by HAN. Further, nothing in this Application or in the employment evaluation process shall be construed as either an offer of employment or an obligation on the part of HAN to provide any benefit to me.

After reading all of the terms of this application. I herby affirm that I understand and agree to the provisions of the same. I also agree that my employment with HAN is on an “at-will” basis, meaning that such employment may be permanently discontinued by either HAN (through discharge or lay/off) or myself through voluntarily quitting at any time without notice. I agree to conform to HAN’s policies and I also agree that I shall be subject to other conditions, which HAN may adopt.
I hereby affirm that I understand and agree the above terms :
Applicants Full Name*
First Last

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Step 1 of 4 - APPLICANT

EMPLOYMENT EXPERIENCE

EMPLOYMENT GAPS

REFERENCES

PRE-EMPLOYMENT STATEMENT