1331 Sabattus Street, Lewiston, ME 04240 
	Phone: 207.782.3617 Fax: 207.777.3911
	Email: info@lppoirier.com
	Website: www.lppoirier.com

PERSONAL INFORMATION 							Date:
Name (Last, First, Middle)	Telephone Number	
		
Address  	Cell  Number	
		
City/State/Zip	DATE AVAILABLE TO START:	

Position Applying For:____________________________        Desired Starting Pay $  ________/ hour

Are you legally authorized to work in the United States?   Yes    No	
Are You Applying For:	Are you available for an occasional:	May We Contact Present Employer?	
F/T    P/T    	    Evening    Weekend	Yes    No	

Do you have a valid ME drivers license ?   Yes    No    CLASS:______	
Drivers License Number	Date of Birth		
	  /        /		

EMPLOYMENT HISTORY - Begin With Most Recent Employment
Dates From                 To	Company Name	City, State	
			
Titles and Duties –	
Reason for Leaving: 	Supervisor’s Name
	Telephone Number	
			
Dates From                   To	Company Name	City, State	
			
Titles and Duties –	
Reason for Leaving: 	Supervisor’s Name
	Telephone Number	
			
Dates From                   To	Company Name	City, State	
			
Titles and Duties –	
Reason for Leaving: 	Supervisor’s Name
	Telephone Number	
			
Dates From                 To	Company Name	City, State	
			
Titles and Duties –
	
Reason for Leaving: 	Supervisor’s Name
	Telephone Number	

** Please attach resume if available **

EDUCATION/TRAINING - Include Technical/Academic Achievements/Courses
Have you obtained a high school diploma or GED certificate?   Yes    No	
School	Name & Location	Diploma/Degree	Subject Of Specialization	
College/University				
Specialized
Courses & Training				

PROFESSIONAL & TECHNICAL INFORMATION - To Be Completed for Licensed/Registered Positions
Type of Certification:	Expiration Date	Certificate No.	Expiration Date	

OTHER SPECIAL SKILLS - List Other Specific Skills You Have to Offer for This Job Opening: 	

REFERENCES - Give the Names of Three Persons Not Related to You
Name	Relationship	Telephone	Occupation	

				

PHYSICAL CONDITION: Do you have any pre-existing medical conditions that could prevent you from performing physical duties:
                                             Yes    No   . 
 If Yes Please explain and attach a Dr’s note clearing you to work.	

HAVE YOU EVER BEEN CONVICTED OF A CRIME:   Yes    No   
If Yes Please explain: 	

ADDITIONAL COMMENTS: ___________________________________________________________________________________________________________

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The information on this application is true and accurate to the best of my knowledge. 
	
Signature 	Date