..:: Northern Maine Medical Center ::..

About Us

Serving the Upper St. John Valley since 1952.

Services

We treat you like family this is supported by response to our customer.

Careers

Click to see the complete information of our Careers.

	Foundation
Special events and the ability for online donatations.

Contact Us

Click to see the complete Information.

Edgar J Paradis Cancer Fund

Power of Prevention

Forest Hill

Madawaska Outpatient Center

APPLICATION FOR EMPLOYMENT FORT KENT, MAINE 04743 Tel. (207) 834-3155 Fax (207) 834-2256 www.nmmc.org E-mail: robin.damboise@nmmc.org or debbie.pelletier@nmmc.org

Last Name*		First Name*
Middle Initial*		Position Applied For*
Street Address
City
State
Zip Code
Phone Number	(area code + number)

Social Security#*		Date Available to Work:
Have you ever been employed by NMMC, FH, or VMA Yes No
Are you legally permitted to work in the U.S.? Yes No
Have you ever been convicted of a crime? Yes No
Available to work: Full-time Part-time Per Diem Temporary or Summer

Select Year(s) completed:
Name of School *		High School
Major/ Course*		Trade/Business
Degree Received		Elementary
		College
Other Schools or Courses
Licenses R.N. L.P.N. Other
License#		Date
Certifications: C.P.R. First-Aid CNA Other
Copy of Certificate Yes No

SKILLS: (that you believe are related to the job for which you are applying)
Typing	w.p.m.	Computer experience: Yes No
Familiar with Windows Microsoft Excel Adobe Microsoft Word
Microsoft Powerpoint Microsoft Publisher Internet Other
Other Office Equipment

NURSING APPLICANTS ONLY
Rank in Order of Preference Choice 1
Rank in Order of Preference Choice 2
Rank in Order of Preference Choice 3
Shift Preferred
I am aware that NMMC, VMA & FH are smoke free campuses. Yes No
I am aware that NMMC, VMA & FH require a medical examination. Yes No

PRIOR WORK HISTORY/EXPERIENCE (List in order, last or current employer first.) Account for any gaps in your employment.
Date	From: To:
Name, Address and Telephone Number of Employer:
Job Title		Starting/Ending Pay
Supervisor’s Name & Title		Reason for Leaving
Description of Responsibilities

Date from to	From: To:
Name, Address and Telephone Number of Employer:
Job Title		Starting/Ending Pay
Supervisor’s Name & Title		Reason for Leaving
Description of Responsibilities

Date from to	From: To:
Name, Address and Telephone Number of Employer:
Job Title		Starting/Ending Pay
Supervisor’s Name & Title		Reason for Leaving
Description of Responsibilities

WORK REFERENCES (Excluding relatives)
	Reference 1	Reference 2	Reference 3
NAME
OCCUPATION
ADDRESS
PHONE NUMBER

I certify, to the best of my knowledge that the information provided in this application is true, and I understand that any intentional misrepresentation of this information could lead to dismissal. I also authorize the hospital to contact my former employers or other persons to make an investigation of my work history and verify my qualifications for the position and release them from any liability or claims arising out of providing this information.

We are an equal opportunity employer. It is our policy that all applicants are considered solely on the basis of qualifications and ability, without regard to race, religion, color, sex, age, national origin, disability or veteran

status.
Note: Application will be kept on file for 6 months from the date noted above.