BucksportRegional Health Center

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BucksportRegional Health Center

Serving the Bucksport region for over 50 years

Become A Patient Patient Portal

Employment Application

WE ARE AN EQUAL OPPORTUNITY EMPLOYER

Qualified applicants receive equal consideration. No question is asked for the purpose of excluding any applicant due to race, color, national origin, religion, age, sex, disability, veteran status, or any other characteristic protected under local, state or federal law.

Step 1 of 4

25%

Employment History
Please list your complete employment history. List present or most recent employer first.
Employer
Employer Name
Name of Supervisor
Address
Street Address Address Line 2 City State ZIP Code
Start Date (month/year)
End Date (month/year)
Reason for leaving
Type of work performed
Employer
Employer Name
Name of Supervisor
Address
Street Address Address Line 2 City State ZIP Code
Start Date (month/year)
End Date (month/year)
Reason for leaving
Type of work performed
Employer
Employer Name
Name of Supervisor
Address
Street Address Address Line 2 City State ZIP Code
Start Date (month/year)
End Date (month/year)
Reason for leaving
Type of work performed
Employment Information
Are you presently employed?
- Yes
- No
If so, may we contact your present employer?
- Yes
- No
If you served in the United States Armed Forces, briefly list the dates, rank, and skills acquired:

Personal Information
Are you able to perform the essential duties of the position you are applying for with or without reasonable accommodation
- Yes
- No
Are you legally authorized to work in the U.S.?
- Yes
- No
Note: you will be required to furnish documents to verify your eligibility for employment in accordance with the Immigration Reform and Control Act and your employment is contingent upon furnishing such documents.
Are you at least 18 years of age?
- Yes
- No
Have you ever been convicted of a crime or are there any pending charges against you?
- Yes
- No
(Note: A conviction does not automatically bar you from employment)
If yes, include details:
As a medical provider, have you ever been, sanctioned by or excluded from the Medicare and/or Medicaid system as a condition of employment?
- Yes
- No
If yes, include details
Please list any special office/software skills
Please list any special equipment skills
Please list any other skills
If hired, when would you be available?
Are you related to any current employees or Board Members of the Bucksport Regional Health Center?
- Yes
- No
If yes, please describe

Certifications, Registrations and Licenses
Certification/Registration/License
Certification, Registration or License Type
Document Number
State
Date Issued
Exp. Date
Temporary/Permanent
- Temporary
- Permanent
Certification/Registration/License
Certification, Registration or License Type
Document Number
State
Date Issued
Exp. Date
Temporary/Permanent
- Temporary
- Permanent
Certification/Registration/License
Certification, Registration or License Type
Document Number
State
Date Issued
Exp. Date
Temporary/Permanent
- Temporary
- Permanent
Certification/Registration/License
Certification, Registration or License Type
Document Number
State
Date Issued
Exp. Date
Temporary/Permanent
- Temporary
- Permanent
References (work references are preferred)
Reference
Name
How They Know You
Email
Phone
Reference
Name
How They Know You
Email
Phone
Reference
Name
How They Know You
Email
Phone
Reference
Name
How They Know You
Email
Phone
I certify that the answers given by me to the foregoing questions and statements are true and correct to the best of my knowledge without consequential omissions of any kind. I agree that the Health Center shall not be held liable in any respect if my employment is rejected or subsequently terminated because of false statements, answers or omissions made by me in this application. I understand that any misleading or incorrect statements may render this application void, and if employed, may lead to employment termination. I understand that a medical examination based on the requirements of the position for which I am being considered may be required. I also voluntarily and knowingly authorize the companies, schools or persons named above to give any information requested regarding my former employment, character and qualifications. I hereby voluntarily and knowingly fully release and discharge, absolve, indemnify, and hold harmless said companies, schools or persons from any and all liability for any damages for issuing this information, except for the malicious and willful disclosure of derogatory facts concerning my employment made for the express purpose of preventing me from obtaining employment, which the party disclosing such facts knows to be untrue. In consideration of my employment, I agree to conform to the rules and regulations of this organization. My employment and compensation can be terminated with or without cause and with or without notice, at any time, at the option of either my employer or me.
Signature
Date

Bucksport Location

Bucksport Regional Health Center
110 Broadway
Bucksport, ME 04416
Phone: (207) 469-7371
Dental: (207) 902-1100 How To Find Us In Bucksport

Hours - Bucksport

Medical: Mon-Wed, Fri 7:00am - 5:30pm
Thu 7:00am - 7:00pm Dental: Mon-Thu 7:30am - 5:00pm
Fri 8:00am - 4:30pm Behavioral Health: Mon-Thu 7:30am – 6:00pm
Fri 8:00am - 5:00pm
Sat 7:30am – 2:30pm Lab: Mon-Fri 7:00am – 4:00pm Walk-In Care: Mon-Fri 7:30am – 9:30am
Sat 8:00am – 3:00pm

Ellsworth Location

Coastal Health Center
37 Commerce Park
Ellsworth, ME 04605
(207) 667-5064

Hours - Ellsworth

Medical: Mon-Fri 7:30am - 5:00pm

BRHC is an equal opportunity provider and employer.

FTCA Deemed
This health center receives HHS funding and has Federal Public Health Service (PHS) deemed status with respect to certain health or health-related claims, including medical malpractice claims, for itself and its covered individuals.

For more information, visit Federal Tort Claims Act (FTCA).

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