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We are always looking for dedicated individuals to join our team of direct support professional staff.

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- Step 1 of 7

Employment Application

Instructions: Please complete the entire application.

1. Applicant Information:

Name *

First

Middle

Last

Address: *

Address Line 1

City

State / Province / Region

Postal Code

Country

Layout

Email *

Phone *

Are you eligible to work in the United States? (Proof of work authorization will be required upon employment) *

Yes
No

Layout

Are you at least 18 years old?

Yes
No

Job position Applying for: *

Do you have a driver’s license?

Yes
No

Who referred you to our company? *

Availability: Please include days/times available to work *

Monday:
Tuesday:
Wednesday:
Thursday:
Friday:
Saturday:
Sunday:

If you are offered employment, when would you be available to begin work? *

Are you able to perform the essential functions of the job position you seek with or without reasonable accommodation? *

Yes
No

What reasonable accommodation, if any, would you request?

2. Emergency Contact:

Who should be contacted if you are involved in an emergency?

Layout

Contact Name: *

Address: *

Relationship: *

Phone: *

3. Education:

Layout

High School: *

Address: *

Layout

From: *

To: *

Did you graduate?

Diploma:

Skills and Qualifications: Licenses, Certificates, Skills, Training, Awards *

4. Military Service:

Layout

Branch

From

To

5. Employment History:

List your current or most recent employment first. Please list all jobs (including self- employment and military service) which you have held, beginning with the most recent, and list and explain any gaps in employment. If additional space is needed, continue to the back page of this application.

Layout

Company:

Phone:

Job Title:

Responsibilities:

Address:

Supervisor:

Dates of Employment (Month/Year):

Reason for Leaving:

Layout

Company:

Phone:

Job Title:

Responsibilities:

Address:

Supervisor:

Dates of Employment (Month/Year):

Reason for Leaving:

Layout (copy)

Company:

Phone:

Job Title:

Responsibilities:

Address:

Supervisor:

Dates of Employment (Month/Year):

Reason for Leaving:

May We Contact Your Present/Former Employers? *

Yes
No

If no, please explain:

6. References:

List any four non-relatives who would be willing to provide a reference for you. Please provide us with at least three professional references, including at least one supervisor.

Layout

Name *

Address *

Address Line 1

City

State

Relationship: *

Phone: *

Layout (2)

Name: *

Address: *

Address Line 1

City

State

Relationship: *

Phone: *

Layout (3)

Name: *

Address: *

Address Line 1

City

State

Relationship: *

Phone: *

Layout (4)

Name: *

Address: *

Address Line 1

City

State

Relationship: *

Phone: *

7. Please provide any other information that you believe should be considered, including whether you are bound by any agreement with any current employer:

8. Disclaimer and Signature:

I certify that the information provided on this application is truthful and accurate. I understand that providing false or misleading information will be the basis for rejection of my application, or if employment commences, immediate termination. I also understand that UBUNTU CARE is an equal opportunity employer, and all applications will be taken understand consideration. I authorize UBUNTU CARE to contact former employers and educational organizations regarding my employment and education. I authorize my former employers and educational organizations to communicate information fully and freely regarding my previous employment, attendance, and grades. I authorize those persons designated as references to communicate information fully and freely regarding my previous employment and education. If an employment relationship is created, I understand that unless I am offered a specific written contract of employment signed on behalf of the organization by its leadership team, the employment relationship will be "at-will." In other words, the relationship will be entirely voluntary in nature, and either I or my employer will be able to terminate the employment relationship at any time and without cause. With appropriate notice, I will have the full and complete discretion to end the employment relationship when I choose and for reasons of my choice. Similarly, my employer will have the right. Moreover, no agent, representative, or employee of UBUNTU CARE, except in a specific written contract of employment signed on behalf of the organization by its leadership team, has the power to alter or vary the voluntary nature of the employment relationship. I HAVE CAREFULLY READ THE ABOVE CERTIFICATION AND I UNDERSTAND AND AGREE TO ITS TERMS.

Date: *

Date

Time

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Founded in April 2019, Ubuntu Care is a private company situated in Portland, Maine.

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