Skip to Main Content
Do Not Show Again
Community & Recreation
How Do I...
Select a Category
Boards and Committees
signing in or creating an account
, some fields will auto-populate with your information.
Sign in to Save Progress
This form has been modified since it was saved. Please review all fields before submitting.
The above-named individual has applied to this office for assistance. We ask your cooperation with providing information regarding their employment with you. We request this information pursuant to 22 M.R.S.A. § 4314. Any other information you can provide is appreciated. Please feel free to use the back of this form.
Social Services Staff
Please Fill Out the Items Below That Are Checked
Date First Worked:
Date and amount of first paycheck:
Date last worked for you:
Date and amount of last paycheck:
Date and amount of any future/outstanding paycheck:
Reason for separation:
Is Worker’s Compensation claim pending?
(Please type your name as a signed agreement)
Leave This Blank:
Receive an email copy of this form.
This field is not part of the form submission.
* indicates a required field
GIS Maps &
Public Data Hub
Agendas & Minutes
Government Websites by
Slideshow Left Arrow
Slideshow Right Arrow