Employment Application Step 1 of 6 - Personal Information 16% Name* First Middle Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code How long have you lived at this address?Telephone No.*Social Security No.Previous Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code How long did you lived at previous address?How did you hear about our company?*CraigslistIndeedCurrent EmployeeCurrent Employee*Have you ever worked here before?*YesNoIf so, when and in what position(s)?*Position(s) applying for:*Rate of pay desired:*Available to work:* Full-time Part-time Are you currently employed?*YesNoAre you 18 years of age or older?*YesNoDate available to start work?* Date Format: MM slash DD slash YYYY Personal References(Give the names of three persons not related to you whom you have known for at least one year) Name Address Occupation Phone Years Known Edit Delete There are no Personal References. Add Personal Reference Maximum number of personal references reached. Educational Background Type of School Name Course of Study Did you graduate? List Degree or Diploma Edit Delete There are no Educational Backgrounds. Add Educational Background Maximum number of educational backgrounds reached. Previous Work ExperienceList last four positions held - list most recent first Employer Name Employer Address Employer Telephone No. Job Duties Reason for Leaving Employment Start Date Employment End Date Ending Salary Supervisor's Name Name Worked Under Edit Delete There are no Work Experiences. Add Work Experience Maximum number of work experiences reached. Please explain all periods of unemployment:Are there any other experiences, skills or qualifications which you feel especially fit you for work with this facility? Are you known to schools/references/employers by any other name(s)?*YesNoPlease list other name(s)*If you have ever been convicted of any of the following (this includes, without limitation, pleading guilty, pleading no contest, or having a finding of guilt) please place check mark next to the conviction. 2903.01 Aggravated Murder 2903.02 Murder 2903.03 Voluntary Manslaughter 2903.04 Involuntary Manslaughter 2903.11 Felonius Assault 2903.12 Aggravated Assault 2903.13 Assault 2903.16 Failing to Provide for a Functionally Impaired Person 2903.21 Aggravated Menacing 2903.34 Patient Abuse or Neglect 2905.01 Kidnapping 2905.02 Abduction 2905.11 Extortion 2905.12 Coercion 2907.02 Rape 2907.03 Sexual Battery 2907.05 Gross Sexual Imposition 2907.06 Sexual Imposition 2907.07 Importuning 2907.08 Voyeurism 2907.08 Public Indecency 2907.12 Felonius Sexual Penetration 2907.25 Prostitution 2907.31 Disseminating Matter Harm to Juvenile 2907.32 Pandering Obscenity 2907.321 Pandering Obscenity Involving a Minor 2907.322 Pandering Sexually Oriented Matter Involving a Minor 2907.323 Illegal Use of Minor in Nudity-Oriented Material or Performance 2911.01 Aggravated Robbery 2911.02 Robbery 2911.11 Aggravated Burglary 2911.12 Burglary 2911.13 Breaking & Entering 2913.02 Theft, Aggravated Theft 2913.03 Unauthorized Use of a Vehicle 2913.04 Unauthorized Use of Property; Unauthorized Access to Computer Systems 2913.11 Passing Bad Checks 2913.21 Misuse of Credit Cards 2913.31 Forgery 2913.40 Medicaid Fraud 2913.43 Securing Writings by Deception 2913.47 Insurance Fraud 2913.51 Receiving Stolen Property 2919.25 Domestic Violence 2921.36 Prohibition of Conveyance of Certain Items onto Grounds of Detention Facility, Mental Health or MRDD Facility 2923.12 Carrying Concealed Weapons 2923.13 Having Weapons while under Disability 2923.161 Improperly Discharging Firearm at or into Habitation or School 2925.02 Corrupting Another with Drugs 2925.03 Trafficking in Drugs 2925.11 Drug Abuse 2925.13 Permitting Drug Abuse 2925.22 Deception to Obtain Dangerous Drugs 2925.23 Illegal Processing of Drug Documents 3716.11 Adulterated Food Have you ever been convicted (this includes, without limitation, pleading guilty, pleading no contest or having a finding of guilt) of any misdemeanor or felony not listed above?*YesNoPlease provide the dates for what and where:* Are you currently:* Accredited Certified Licensed Licensure None License and/or Certifications License/Certification State of Issuance Licensing Agency Expiration Date Number If issuing state is not Ohio, have you applied for reciprocity? Edit Delete There are no License and/or Certifications. Add License and/or Certification Maximum number of license and/or certifications reached. If an examination is required, what date are you scheduled to take the exam? Date Format: MM slash DD slash YYYY Has your professional license ever been revoked, suspended or subject to any disciplinary action?*YesNoIf yes, list where, for what and give dates:* Applicant StatementI certify that all the information set forth during my employment application process is true and complete. I understand and agree that any falsification, misrepresentation or omission either on the employment application form or in my responses to questions asked during the interviewing or examination process may disqualify me from further consideration for employment, or if employed by the Company, will subject me to immediate termination, whenever the falsification or omission is discovered. In this regard, where an item is left blank on the employment application, it is because there is no information within its scope. My signature authorizes the Company or its authorized agents to conduct a thorough investigation of all statements, written and oral, made by me during the employment application process, including without limitation, information concerning my employment positions, law enforcement record and educational background. I hereby authorized all persons, companies, or other entities connected with any such informational request, including without limitation, current or prior employers and law enforcement agencies to provide any and all information they may have regarding me or my employment. I release and agree to indemnify the Company, its authorized agents and its employees and all other persons, companies, and other entities from any and all liability arising out of such investigation, including without limitation, any liability for furnishing information or for taking any action based on the information provided. I authorize and consent to the submission of my fingerprints and a request for a criminal records check to comply with Ohio Senate Bill 160. I understand that if I am made a contingent offer of employment and the results of the criminal records check indicate I have been convicted (this includes, without limitation, pleading guilty, pleading no contest or having a finding of guilt) of one or more of the crimes listed on the previous page and the company determines I do not meet the personal character standards developed by the Ohio Department of Health, I will be subject to immediate termination. I further understand that if the Company does not receive the criminal records check back within 60 days my employment will also be terminated. I may be eligible for rehire upon receipt and review of the results of the criminal records check. I understand that a drug and/or alcohol screen may be required before and during my employment. In addition, I authorize a medical examination, including a drug and/or alcohol screen, by an examiner selected by the Company if I am made a contingent offer of employment. I release and agree to indemnify the Company, its authorized agents and its employees and all other persons, companies and other entities from any and all liability arising out of any medical examination or drug/alcohol screen or for the taking of any action based on the results of any medical examination or drug/alcohol screen. I certify that I am a citizen of the United States and, if not, I can provide required documentation permitting me to work in the United States. I understand and agree that if I am employed, my employment is at-will so that I may terminate my employment at any time and for any or no reason. Likewise, the Company may terminate my employment at any time and for any or no reason. I also understand and agree that nothing contained in the employment application or in the granting or conducting of any interview or anything set forth in any oral or written statement, communication, or policy now or in the future constitutes or creates or is intended to constitute or to create a contract or promise between me and the Company for employment, hours of work, or for the providing of benefits. Moreover, I acknowledge that the Company reserves the right to modify, revoke, suspend, terminate or change any or all of its plans, policies, or procedures at any time, without prior notice. No promises or guarantees regarding employment, hours of work, or for the providing of benefits have been made to me and I understand and agree that no such promise or guarantee is binding on the Company unless they are expressed promises, made in writing, and signed by the Administrator of the Company. Signature*CAPTCHAApplied Date Date Format: MM slash DD slash YYYY This iframe contains the logic required to handle Ajax powered Gravity Forms.