Your Medical Home

Phone: (207) 288-5081
Emergencies: 911

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Serious consideration will only be given to applications submitted with complete information. Please be sure to include all relevant information.
* Denotes required information.

Application for Employment
Email Address (*)

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Applicant Name (*)

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Address (*)

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City (*)

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State (*)

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Zip Code (*)

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Phone (area code + 7 digits) (*)

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Cell phone

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CV Upload

Invalid Input Maximum file size 2000KB. Accepted file types are .doc, .docx, .pdf, .cwk, .rtf, .odf, AND .txt
Position applied for

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Date available for employment

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Employment status and shift desired

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US Citizen

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If answer is NO to above, please state type of Visa or Alien Registration #

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How were you referred for employment?

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Please be specific. Which newspaper, website, employer, publication or firm referred you?

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Have you worked here before?

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When?

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List professional or technical licenses, certifications or registrations.

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Have you ever been convicted of a crime or plead guilty or no lo contendre to a crime?

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If YES, please explain.

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EDUCATION



High School Name

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School Address

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Highest grade complete

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Course of study

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Vocational School Name

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Vocational school address

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Years complete

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Course of study

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Certificate or degree received

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CNA Registration Number

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College Name

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College address

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Years completed

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Degree received

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Major concentration

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Graduate School Name

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Graduate school address

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Degree received

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Applicable courses, training, work experience and skills

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EMPLOYMENT HISTORY



Present or last employer

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Address

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Phone (area code + 7 digits)

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Dates of employment (from - to)

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Final Salary

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Reason for leaving

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Job title and duties

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Name and title of supervisor

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Second last employer

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Address

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Phone (area code + 7 digits)

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Dates of employment (from - to)

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Final Salary

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Reason for leaving

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Job title and duties

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Name and title of supervisor

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Third last employer

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Address

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Phone (area code + 7 digits)

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Dates of employment (from - to)

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Final Salary

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Reason for leaving

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Job title and duties

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Name and title of supervisor

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THIS SECTION TO BE COMPLETED BY RN AND LPN APPLICANTS



Please check the areas in which you have experience.

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Please specify

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Reference 1 — Director of School of Nursing (if a recent graduate)

Name

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School Name/Address

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Phone

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Reference 2 — Director of Nursing (most recent)

Name

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Facility Name/Address

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Phone

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THIS SECTION FOR APPLICANT LICENSE/CERTIFICATION INFORMATION



License or Certificate Number

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State of Issue

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Expiration Date

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Name of any other state in which you are registered/licensed. Indicate registration/license numbers and expiration dates.

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May we contact your present employer?

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By checking the box below, I certify that the above information is correct and complete to the best of my knowledge. I understand that omissions or false statements on this application are cause for denial of employment or subsequent dismissal. I authorize the Hospital to contact my former employers for references and to conduct an agency check for criminal convictions. I understand that, if employed, I will be an "at will employee" and may terminate my employment or be terminated by the Hospital at any time, for any reason. I agree, if employed, to abide by Hospital policies. (*)

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The following is provided to verify that you are a human being: (*)

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Mount Desert Island Hospital; Critical Access to Quality Care Since 1897
10 Wayman Lane • Bar Harbor, ME • 04609 • (207) 288-5081

© 2014  Mount Desert Island Hospital, all rights reserved.