Downeast Horizons, Inc. Employment Application

We invite you to complete our secure online employment application form. Your reply is confidential and information obtained will be used specifically for employment consideration. Please respond to all questions. If any questions are left unanswered, your application will be considered incomplete and may not be considered for possible employment. If you would rather apply via mail, download and complete our application PDF and mail to:

M.D.I. Center

1200 State Highway 3
Bar Harbor, ME 04609
(207) 288-4234
Fax (207) 288-1056

Ellsworth Center

77 Union Street
Ellsworth, ME 04605
(207) 667-7464
Fax (207) 667-1977

Brewer Office

38 Dirigo Dr.
P.O. Box 906

Brewer, ME 04412
(207) 945-0068
Fax (207) 945-6929

We are a drug-free workplace.

* = required field

About You

Name *
Email *
Home Address*
City, State, Zip *

Telephone *

Alternate


Social Security # *

Driver's Lic. # *


Position Applying for


Date available *

Expected earnings *


Please check ALL that you would be available and willing to work:
(Required to check one)


Full-time (33-40 hrs.)

Part-time

Relief

Evening Hours

Day Hours

Weekends

Awake Overnights

Block Shifts


How were you referred to Downeast Horizons, Inc.?


Internal

Newspaper

Online

Job Corps

DEH Website

Current Employee

Other


Have you ever applied for a position with Downeast Horizons? * YesNo

If yes, when?

Have you previously been employed with Downeast Horizons, Inc.? *YesNo

If yes, when?
If yes, when?


From

To


Are you 18 years of age or older? * YesNo

Are you legally eligible to work in the United States? * YesNo
All new hires must produce proof of identity and employment eligibility upon hire in accordance with the Immigration Reform and
Control Act.

Have you ever been convicted of any crime? *YesNo
Please include in- and out-of-state criminal records.

If yes, please check any that apply:


I have NEVER been convicted of a crime

Criminal Mischief

Writing Bad Checks

Assault

Unauthorized Taking or Transfer

Falsifying Evidence

Unlawful Sexual Contact

Disorderly Conduct

Criminal Trespass

Terrorizing

Theft

Unauthorized Use of a Motor Vehicle

Illegal Possession / Use of Drugs


Other, please list any other crime for which you have been convicted of:




Please list any motor vehicle violations that you have received in your history as a driver.YesNo
Please include in- and out-of-state violations.
If yes, please check all that apply: *


Failure to report an accident

Reckless Driving

Speeding

Negligent Homicide Using a Vehicle

Failure to Provide Proof of Insurance

Outdated Inspection

Accident Regardless of Fault

Driver's License Suspension

Driving Too Close

OUI / DUI

Driving to Endanger

Failure to Stop at Stop Sign

Hit and Run

Passing a School Bus

Driving with Suspended License


Other, please list any other violations that would be listed on your driving record report:




Do you have a prior employment history of, or have you ever been investigated for child abuse or abuse to an individual with disabilities? *
YesNo

If yes, please explain:


Have you ever been substantiated for abuse, neglect or exploitation by the State of Maine Adult Protective Services against an adult with mental retardation or autism? *
YesNo

If yes, please explain:


Work History

(Indicate most recent position first)

Employer 1 *
Address *
City, State, Zip *
Telephone *
Email

Dates of Employment *


From

To

Immediate Supervisor *
Reason for Leaving *
Position*

Duties/Responsibilities *

May we contact this employer for a reference?* YesNo

If not, why not?


Employer 2
Address
City, State, Zip
Telephone
Email

Dates of Employment


From

To

Immediate Supervisor
Reason for Leaving
Position

Duties / Responsibilities

May we contact this employer for a reference? YesNo

If not, why not?


Employer 3
Address
City, State, Zip
Telephone
Email

Dates of Employment


From

To

Immediate Supervisor
Reason for Leaving
Position

Duties / Responsibilities

May we contact this employer for a reference?YesNo

If not, why not?


Educational Background

High School *

Years of School *

Graduate? *
YesNo




College


Years of School

Graduate?
YesNo


Course or Major
Degree


Post Graduate


Years of School

Graduate?
YesNo


Course or Major
Degree


Business / Trade


Years of School

Graduate?
YesNo


Course or Major
Degree


References

Name *
Occupation *
Address *
City, State, Zip *
Telephone *
Email


Name *
Occupation *
Address *
City, State, Zip *
Telephone *
Email


Name *
Occupation *
Address *
City, State, Zip *
Telephone *
Email


Please state any additional information you feel may be helpful in considering your application, such as major accomplishments, business or professional organizations, service in the armed forces (including dates of duty), special skills or technical proficiencies in various software packages.


In consideration of my employment by Downeast Horizons, Inc. (DEH), I understand and agree to conform to:

  1. DEH may make a thorough review of my experience and education and further may verify all application and/or interview materials and investigate all statements and references contained in my application. I release from liability any person giving or receiving such information. Falsification, misrepresentation, or omission of facts so given, or other derogatory information discovered as a result of this review may prevent my being hired, or if hired, may subject me to immediate dismissal.
  2. I understand that my employment is at will, which means that either DEH, Inc. or I am free to terminate my employment with or without cause and with or without notice, at any time.
  3. I understand that my first 90 days will be an introductory period.
  4. I understand that the terms and conditions of my employment may be changed, with or without notice, by DEH.
  5. Although DEH makes every effort to accommodate employee’s preferences, the needs of persons served by DEH may, at times, make the following conditions mandatory: Overtime, shift work, holiday work, a rotating schedule, overnight shifts, and/or a work schedule other than that for which I may have been hired. I understand and accept these conditions of my future or continuing employment. I further understand that if I am employed, I am employed for an indefinite period of time and DEH may change wages, hours, and the terms and conditions of my employment at any time.
  6. In consideration for my employment and my being considered for employment by DEH, I agree to follow the policies, rules, practices, and regulations of DEH and acknowledge that these policies, rules, practices, and regulations may be changed, interpreted, withdrawn, or added to by DEH at any time at its sole discretion and without any prior notice to me. I further acknowledge that my employment may be ended and any offer of employment if such is made, may be withdrawn with or without prior notice at any time for any reason at the option of DEH or myself.
  7. I understand that representatives of DEH do not have the authority to enter into any agreement for employment for any specified period of time. Further, no representative of DEH may guarantee other personnel move either prior to commencement of employment or after I have become employed. Assurances of any benefits or terms and conditions of employment, or any agreement contrary to the foregoing, may not be entered into.
  8. DEH reserves the right, due to Federal Medicaid Regulations and other state and federal laws, to complete criminal record, child protective, motor vehicle, and other eligibility for employment checks on all applications and employees. I understand and am willing to use my personal vehicle as part of my position at DEH if it becomes necessary. I am willing to show proof of current automobile insurance coverage.
  9. I understand that the position I am applying for may involve implementing crisis prevention and intervention services which may include lifting, pulling, and guiding persons with disabilities against potential resistance. I understand this as a condition of employment and have no reason to believe I cannot implement these or other responsibilities of the position for which I am applying with or without reasonable accommodation. I understand that some job classifications require a pre-employment physical and that if I am offered the job I will be expected to report to the DEH preferred provider at no cost to me. If the physical reveals conditions which will make it dangerous for me to perform the essential job functions of this position, I understand that the job offer may be withdrawn.
  10. I have read the current position description, and other relevant documentation, had the opportunity to ask questions, and understand all. My signature indicates that DEH may contact the employers I have listed on this application.

Applicants shall receive consideration without discrimination.

An Equal Opportunity Employer

Applicants are considered regardless of race, color, age, sex, religion, national origin, sexual orientation, marital or veteran status, physical or mental disability or other protected classification as defined by applicable law and regulation.


I have read and accept all terms noted above. * YesNo


Voluntary Affirmative Action Form

The information requested within this section will be used solely for our diversity initiative. Your provision of this information is optional. Your decision not to complete this section will not affect consideration of your application or subject you to any adverse treatment. When you have completed this form, please separate it from your application and send it to the Downeast Horizons, Inc., Director of Human Resources.

Ethnic Group: (See Definitions Below)


Hispanic

Mixed Ethnic

Asian or Pacific Islander

Caucasian

African American

Middle Eastern




Sex MaleFemale

Date of Birth



Disability YesNo

Qualified Disabled or Vietnam Veteran
(Downeast Horizons, Inc. will make reasonable accommodations for otherwise qualified applicants.)YesNo


Code Ethnic Background Categories  The following definitions may be of help to you in completing this sheet:

Native American or Alaskan Native: People whose ancestry is any of the original peoples of North America, and who maintain cultural identification through tribal affiliation or community recognition.

Asian or Pacific Islanders: People whose ancestry is any of the original peoples of the Far East, Southeast Asia, the Indian subcontinent, or the Pacific Islands. This area includes, for example, China, Japan, Korea, the Philippine Islands, Hawaii, Tahiti, the Indian subcontinent, Asian subcontinent, and Samoa.

African American, Not of Hispanic Origin: People whose ancestry is of African descent.

Hispanic: All persons of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish or Portuguese culture or origin, regardless of race.

Caucasian, Not of Hispanic Origin: People whose ancestry is any of the original peoples of Europe.

Middle Eastern American: People whose ancestry is from the Middle East countries: Saudi Arabia, United Arab Emirates, Iraq, Iran, Syria, Egypt, Israel, Jordan, Qatar, Tunisia, Kuwait, Yemen, Southern Yemen, Oman, Bahrain, Lebanon.

Mixed Ethnic Background: A combination of ethnic background that includes two or more of the six major categories — Native American or Alaskan, Asian or Pacific Islander, African American, Hispanic, Middle Eastern and Caucasian.

Disability: Any physical and/or mental condition that might substantially limit you in securing, retaining, or advancing in employment. If you are disabled, you should check the “yes” box above. The information will be kept confidential and will be used only in conjunction with our diversity initiative under the Rehabilitation Act of 1973.


Signature *

Date *



Downeast Horizons, Inc. is committed to providing equal opportunity in its recruitment, admissions, educational programs, activities, and employment without discrimination on the basis of race, color, religion, national origin, age, sex, or disability.
Information on this form is confidential and will not be used for discriminatory purposes.