Safe Residential Care LLC Employment Application Download, save, and fill out his form, then email to: [email protected] Download Application Form Or fill the application online below Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. - Step 1 of 8LayoutName *FirstMiddleLastDate Today *Street Address *LayoutCity, State, ZIP *Email *EmailConfirm EmailHome Phone *Cell PhoneNextLayoutPosition Desired *Salary Expected *I am authorized to work in the United States: *YesNoLayoutDo You have a Valid Driver's License? *YesNoState *Has Your Driver's License ever been revoked? *YesNoOn what date can you begin? *LayoutAre you available to work *Full timePart TimeTemporaryCan You travel for work if needed? *YesNoPreviousNextMonday *1ST SHIFT (8:00 AM TO 4:00 PM)2ND SHIFT (4:00 PM TO 12:00 AM (MIDNIGHT)3RD SHIFT (12:00 AM TO 8:00 AM)Tuesday *1ST SHIFT (8:00 AM TO 4:00 PM)2ND SHIFT (4:00 PM TO 12:00 AM (MIDNIGHT)3RD SHIFT (12:00 AM TO 8:00 AM)Wednesday *1ST SHIFT (8:00 AM TO 4:00 PM)2ND SHIFT (4:00 PM TO 12:00 AM (MIDNIGHT)3RD SHIFT (12:00 AM TO 8:00 AM)Thursday *1ST SHIFT (8:00 AM TO 4:00 PM)2ND SHIFT (4:00 PM TO 12:00 AM (MIDNIGHT)3RD SHIFT (12:00 AM TO 8:00 AM)Friday *1ST SHIFT (8:00 AM TO 4:00 PM)2ND SHIFT (4:00 PM TO 12:00 AM (MIDNIGHT)3RD SHIFT (12:00 AM TO 8:00 AM)Saturday *1ST SHIFT (8:00 AM TO 4:00 PM)2ND SHIFT (4:00 PM TO 12:00 AM (MIDNIGHT)3RD SHIFT (12:00 AM TO 8:00 AM)Sunday *1ST SHIFT (8:00 AM TO 4:00 PM)2ND SHIFT (4:00 PM TO 12:00 AM (MIDNIGHT)3RD SHIFT (12:00 AM TO 8:00 AM)PreviousNextLayoutEmergency Contact Name *Emergency Contact Telephone: *Relationship? *Do you know of any reason you cannot perform the essential functions of the job for which you are applying with or without reasonable accommodation? *YesNoLayoutHave you ever gone by a name other than the one listed above? *YesNoHave you ever been convicted of a crime? *YesNoIf yes, please list here:If yes, please, explain and include dates:LayoutHave you ever had a substantiated cas brought against you by child and/or adult protective services? *YesNoIf yes, please, explain and include dates:LayoutPlease list all Licenses and certifications you now hold: *DSPCRMACPR/FIRST AIDCPILCSWLCPCMSWLADCCANLPNRNMHRTOther:PreviousNextHigh SchoolSchool Name & LocationCourse Of StudyYear CompletedDegree or diploma?CollegeSchool Name & Location Course Of Study Year CompletedDegree or diploma? GraduateSchool Name & Location Course Of StudyYear Completed Degree or diploma?Business/Trade TechnicalSchool Name & LocationCourse Of StudyYear Completed Degree or diploma?PreviousNextEmployment OneEmployment HistoryCompany, Agency nameAddressJob titleWeekly PaySupervisorMay We contact this Employer?YesNoPhoneEmployment dates: FromDD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Employment dates: ToDD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Reason For LeavingIf No, please explain why:Employment TwoEmployment History Company, Agency name Address Job title Weekly Pay Supervisor May We contact this Employer? YesNoPhoneEmployment dates: From DD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Employment dates: To DD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Reason For LeavingIf No, please explain why: Employment ThreeEmployment History Company, Agency name Address Job titleWeekly Pay SupervisorMay We contact this Employer? YesNoPhoneEmployment dates: From DD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Employment dates: To DD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Reason For LeavingIf No, please explain why: PreviousNextLayoutDid you serve in the US Armed Forces? *YesNoIf yes, in which branch?Describe any military training you received that you believe would be pertinent to the position for which you are applying. PreviousNextLayoutReference Name *Reference Name *Reference Name *Reference Telephone: *Reference Telephone: *Reference Telephone: *EQUAL OPPORTUNITY EMPLOYER Safe Residential Care is an equal opportunity employer and does not discriminate against employees or job applicants based on race, religion, color, sex, age, national origin, mental and physical disability, veteran or family status, genetic information, or any other status or condition protected by applicable federal, state, or local laws, except where a bona fide occupational. qualification applies. BACKGROUND CHECK INFORMATION Safe Residential Care (SRC) receives background information on all its employees from the State Bureau of Investigation, State of Maine Department of Health & Human Services Child Protective Services; and the State of Maine Bureau of Motor Vehicles. If I ·have lived in states other than Maine, I further authorize SRC to complete appropriate out-of-state background checks. Applicants should understand that any information that may be listed on these checks that relate to incidents in the applicant's past, affecting their relationship with the consumers/clients in the program, the staff, or the operation of the program, may be considered a sufficient reason to reject their employment application or could mean their immediate termination. The information I have provided in this employment application is true, correct, and complete. I understand my application will be rejected if false, incomplete, omitted, or misrepresented information is discovered, and I may be terminated if after I am employed, it is discovered. I authorize SRC to contact and obtain information from previous employers, educational institutions, and "references" I provided, and any other party necessary to verify the accuracy of the information I disclosed in this application, a related employment resume, or a personal interview. This application is not an employment agreement. If I accept an offer of employment from SRC, I understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with SRC is of an "at will" nature. My employment is at the will of the employer, and either SRC or I may at any time terminate the employment relationship with or without cause and without prior notice unless required by law. I understand that no one, other than the executive director of the agency, has the authority to enter into any employment agreement with terms contrary to the foregoing and then only in writing signed by the executive director. I fully understand and accept all terms and conditions of the above statement. PreviousSubmit