Staff Application

(List each job held. Start with your present or last job. Include military service assignments and volunteer activities.)

PRE-EMPLOYMENT STATEMENT

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 Company, termination of my employment.

I authorize representatives of Company to contact educational institutions, state and federal agencies (to conduct driving record checks and criminal history records checks) and employers designated in this Application for purposes of verification and investigation of my educational, criminal record, driving record, and employment background and performance. Such individuals and organizations are authorized to release such information as may be requested by a Company 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 Company, termination of my employment. Should I be employed by Company, I understand that I could be subject to an outside probe if accused of wrongdoing.

Please be aware that Company 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 and for New Hampshire employees to New Hampshire Employment Security within 20 days of hire. The Company complies with this legal requirement.

I certify that I am neither suspended nor excluded from participation in Medicare of state health programs under provisions of sections 1128 or 1156 of the Social Security Act. Company desires to maintain a safe and healthy working environment for the benefit of all employees. Where there is a reasonable question as to whether or not I can safely perform the duties of my job due to my physical or mental condition, Company shall have the right to require that I submit to physical or mental examinations for purposes of receiving medical confirmation that I can safely perform the duties of my job. Any and all such examinations shall be for job-related purposes only and shall be performed by a medical advisor or advisors selected and paid for by Company. I hereby release all such information to Company and waive any right of confidentiality.

Submission of the application does not entitle me to be interviewed by Company. 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 Company to provide any benefit to me. This Application shall be pending, unless withdrawn by me, until Company makes a decision on whether or not to hire me or until the 30th day after submission of this application to Company, whichever occurs first. If no action is taken on my Application within a 30-day period, I understand that I must re-apply to Company in order to be considered for employment. Should I be employed by Company, I agree to comply with any and all employment rules and policies of Company.

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 the Company is on an “at-will” basis, meaning that such employment may be permanently discontinued by either the Company (through discharge or lay/off) or myself through voluntarily quitting at any time without notice and without any recourse of any kind by either party. I expressly agree and understand this is the entire agreement between the Company and me on the subject of discharge, termination and/or layoff, and it may be changed only by an agreement in writing signed by the President of the Company. I agree to conform to the Company’s rules and I also agree that I shall be subject to other conditions, which the Company may adopt. I affirm the information in this application is true and complete, and any intentional deception herein may be considered sufficient cause for dismissal.