Are you legally eligible for employment in this country? *
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Yes
No
Will you require MEMIC immigration sponsorship now (for example, permanent residence related filings, H-1B sponsorship, Form I-983 training plan, etc.)? *
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Yes
No
Will you require MEMIC immigration sponsorship in the future? *
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Yes
No
This internship pays $22/hour. Is this inline with your desired compensation? *
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Yes
No
If you are under 18, can you furnish a work permit? *
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Yes
No
What is the highest level of education you have completed? *
Please select None
GED
High School
Associates Degree
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What state do you reside in? *
Please select I do not reside in the US
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MEMIC's internship program is onsite at our Portland, ME headquarters and we do not provide housing assistance. Will you be able to relocate here for the summer? *
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Yes
No
Will you travel if the job requires it? *
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Yes
No
Are you able to perform the "essential functions" of the job for which you are applying (with or without reasonable accommodation)? *
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Yes
No
Have you entered into an agreement with any former employer or other party (such as a noncompetition agreement) that might, in any way, restrict your ability to work for our company? If yes, please explain. *
Have you ever been employed here before? If so, what dates? *
I hereby certify that the information contained in the employment application I submit to Maine Employers’ Mutual Insurance Company, hereinafter referred to as (“MEMIC”) or (“the Company”) is true and complete to the best of my knowledge. I understand that material omissions or falsification of this application may result in my disqualification from consideration for employment or dismissal from employment. I understand that my employment is subject to a satisfactory check of references. I authorize MEMIC and/or its designees the right to investigate the information given and to secure additional information, if necessary. I authorize my previous employers, educational institutions and all other individuals and organizations listed in this application form to provide information about my employment, work habits and character. I agree that MEMIC, and/or its designees and my previous employers, educational institutions and all other individuals and organizations listed in this application form will not be held liable in any respect if an employment offer is not made, is withdrawn, or my employment is terminated because of furnishing necessary information incident to the employment process. I understand that MEMIC is in no way obligated to provide employment and I am in no way obligated to accept employment, if offered. This application does not bind either party, and the statements contained herein do not constitute and should not be interpreted to constitute any sort of contract of employment for a specific period of time. I understand this application for employment is valid for 30 days only. Consideration for employment after 30 days requires a new application. I understand that upon offer and acceptance of a position with MEMIC, I will be required to provide documentation establishing my identity and eligibility to be legally employed in the United States. I understand that employment at MEMIC is employment at will. Employment may be terminated with or without cause at any time by me or by the Company. Terms and conditions of employment with MEMIC may be modified at the sole discretion of the Company with or without cause and with or without notice, except as may be required by law. I also understand that other than the President of the Company, no one has the authority to make any agreement for employment other than for employment at will or to make any agreement limiting the Company’s discretion to modify terms and conditions of employment. MEMIC is an equal opportunity employer, considering all qualified applicants and employees for hiring, placement, and advancement, without regard to a person’s race, national origin, color, religion, age, gender, sexual orientation, gender identity or expression, disability, genetic information, military and veteran status, or any other protected status under applicable federal, state or local law. If you agree to the above, please type your first and last name and today's date. *
Voluntary Self-Identification
For government reporting purposes, we ask candidates to respond to the below self-identification survey.
Completion of the form is entirely voluntary. Whatever your decision, it will not be considered in the hiring
process or thereafter. Any information that you do provide will be recorded and maintained in a
confidential file.
As set forth in Opportunities at MEMIC’s Equal Employment Opportunity policy,
we do not discriminate on the basis of any protected group status under any applicable law.
Gender
Please select Male
Female
Decline To Self Identify
Are you Hispanic/Latino?
Please select Yes
No
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Please identify your race
Please select American Indian or Alaskan Native
Asian
Black or African American
Hispanic or Latino
White
Native Hawaiian or Other Pacific Islander
Two or More Races
Decline To Self Identify
Race & Ethnicity Definitions
If you believe you belong to any of the categories of protected veterans listed below, please indicate by making the appropriate selection.
As a government contractor subject to the Vietnam Era Veterans Readjustment Assistance Act (VEVRAA), we request this information in order to measure
the effectiveness of the outreach and positive recruitment efforts we undertake pursuant to VEVRAA. Classification of protected categories
is as follows:
A "disabled veteran" is one of the following: a veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or a person who was discharged or released from active duty because of a service-connected disability.
A "recently separated veteran" means any veteran during the three-year period beginning on the date of such veteran's discharge or release from active duty in the U.S. military, ground, naval, or air service.
An "active duty wartime or campaign badge veteran" means a veteran who served on active duty in the U.S. military, ground, naval or air service during a war, or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense.
An "Armed forces service medal veteran" means a veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985.
Veteran Status
Please select I am not a protected veteran
I identify as one or more of the classifications of a protected veteran
I don't wish to answer
Voluntary Self-Identification of Disability
OMB Control Number 1250-0005
Expires 04/30/2026
Why are you being asked to complete this form?
We are a federal contractor or subcontractor. The law requires us to provide equal employment opportunity to qualified people with disabilities. We have a goal of having at least 7% of our workers as people with disabilities. The law says we must measure our progress towards this goal. To do this, we must ask applicants and employees if they have a disability or have ever had one. People can become disabled, so we need to ask this question at least every five years.
Completing this form is voluntary, and we hope that you will choose to do so. Your answer is confidential. No one who makes hiring decisions will see it. Your decision to complete the form and your answer will not harm you in any way. If you want to learn more about the law or this form, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp .
How do you know if you have a disability?
A disability is a condition that substantially limits one or more of your “major life activities.” If you have or have ever had such a condition, you are a person with a disability. Disabilities include, but are not limited to:
Alcohol or other substance use disorder (not currently using drugs illegally)
Autoimmune disorder, for example, lupus, fibromyalgia, rheumatoid arthritis, HIV/AIDS
Blind or low vision
Cancer (past or present)
Cardiovascular or heart disease
Celiac disease
Cerebral palsy
Deaf or serious difficulty hearing
Diabetes
Disfigurement, for example, disfigurement caused by burns, wounds, accidents, or congenital disorders
Epilepsy or other seizure disorder
Gastrointestinal disorders, for example, Crohn's Disease, irritable bowel syndrome
Intellectual or developmental disability
Mental health conditions, for example, depression, bipolar disorder, anxiety disorder, schizophrenia, PTSD
Missing limbs or partially missing limbs
Mobility impairment, benefiting from the use of a wheelchair, scooter, walker, leg brace(s) and/or other supports
Nervous system condition, for example, migraine headaches, Parkinson’s disease, multiple sclerosis (MS)
Neurodivergence, for example, attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder, dyslexia, dyspraxia, other learning disabilities
Partial or complete paralysis (any cause)
Pulmonary or respiratory conditions, for example, tuberculosis, asthma, emphysema
Short stature (dwarfism)
Traumatic brain injury
Disability Status
Please select Yes, I have a disability, or have had one in the past
No, I do not have a disability and have not had one in the past
I do not want to answer
PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. This survey should take about 5 minutes to complete.