Applicant Information
Name: Email:
Physical Address: Mailing Address:
City: City:
State:   Zip: State:   Zip:
Telephone #: Mobile Phone #:
 
Referral Information
Referral Source:   Specify (if applicable):
 
Have you previously applied for or worked for Support Solutions or any of its divisions?   
  Dates (if yes):
 
Do you have relatives or friends who work or have worked for Support Solutions?   
  Name (if yes):
 
If referred by a current Support Solutions employee please provide the following:   Name:
  Relationship:
 
Availability
For what type of position(s) are you applying?

What type of employment is desired? (check all that apply) Full Time Part Time Relief

Please indicate which shifts you are available to work (check all that apply, scheduled times will vary):
Shift All Sunday Monday Tuesday Wednesday Thursday Friday Saturday
1st
2nd
3rd

Are you available to work: (check all that apply) Weekdays Weekends Holidays
 
Transportation
Do you have reliable transportation?
Is your vehicle insured? Proof of automobile insurance is required.
Do you have a valid Maine driver's license?
License # (if yes):
 
Other
Do you have the legal right to reside and work in the U.S.? (Proof of citizenship or resident alien status will be required after employment.)
 
Have you ever pled "guilty" or "no contest" to or been convicted of a crime?
     If yes, please explain:
 
Have you ever been administratively determined by a federal, state or local government agency to have committed abuse, neglect, or fraud?
     If yes, please explain:
 
Do you need special accommodations to be able to perform the essential functions of the position for which you are applying?
     If yes, please explain:
 
What, if any, is your experience working with children/adults with special needs?
 
Educational Background
School Name Address Number of years Diploma / Degree Major

Other Training or Certificates

Name Address Date

Other specialized training / educational experience relevant to position(s).

 
Professional References
Please list professional references not related to you. Professional references may be used in addition to employment references, for example, current/former supervisor, professor, clergy, coach etc.

Name:  Telephone:  Number of Years Known: 
Affiliation:  Address: 

Name:  Telephone:  Number of Years Known: 
Affiliation:  Address: 

Name:  Telephone:  Number of Years Known: 
Affiliation:  Address: 
 
Employment History
List employment history beginning with the last or current position. Please include any work performed on a volunteer basis, time spent in military service, or full time education. Please include at least your last three employers.

 
Employer Name:  Supervisors Name: 
Employer Phone:  Supervisors Title: 
Employer Address:  Employed From (MM/YY):   To: 
Job Title:  Pay ($xx.xx):   Per: 

Briefly describe your duties and responsibilities:

What was your reason for leaving?

May we contact this employer?  
 

 
Employer Name:  Supervisors Name: 
Employer Phone:  Supervisors Title: 
Employer Address:  Employed From (MM/YY):   To: 
Job Title:  Pay ($xx.xx):   Per: 

Briefly describe your duties and responsibilities:

What was your reason for leaving?

May we contact this employer?  
 

 
Employer Name:  Supervisors Name: 
Employer Phone:  Supervisors Title: 
Employer Address:  Employed From (MM/YY):   To: 
Job Title:  Pay ($xx.xx):   Per: 

Briefly describe your duties and responsibilities:

What was your reason for leaving?

May we contact this employer?  
 

 
Employer Name:  Supervisors Name: 
Employer Phone:  Supervisors Title: 
Employer Address:  Employed From (MM/YY):   To: 
Job Title:  Pay ($xx.xx):   Per: 

Briefly describe your duties and responsibilities:

What was your reason for leaving?

May we contact this employer?