First Name *

Last Name *

Phone *

Email *

Social Security Number *

Address *

City *

State *

Zip Code *

Position Applied For: *

Direct Care Staff - Full Time

Direct Care Staff - Part Time

Date You Can Start? *

Desired Salary

Are You Employed Now? *

Ever applied to this company before?

Are you at least 18 years old? *

Do you have at least a High School Diploma or GED? *

Do you have a valid Driver’s License? *

Driver's License # & State of Issue? *

Do you have Current Auto Insurance? *

Do you have a Personal reliable vehicle for transporting clients? *

Do you have no more than 5 points on driving record. *

Have you lived in Ohio the last 5 years? *

High School - Name & Location, Years Attended, Subjects Studied *

College or Trade School - Name & Location, Years Attended, Subjects Studied *

Subject Of Special Study/Research Work *

Special Training *

Special Skills *

U.S. Military or Naval Service? If so, your branch and rank. *

Date Worked From To *

Employer Name *

Employer Address *

Position Held *

Job Duties *

Reason For Leaving *

Date Worked From To (2)

Employer Name (2)

Position Held (2)

Job Duties (2)

Reason For Leaving (2)

Date Worked From To (3)

Employer Name (3)

Position Held (3)

Job Duties (3)

References - List 3 (Name, Phone Number, Address, Relationship, Years Know) *

Authorization

I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal.

I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information.

I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative.

This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws.

I understand that a consumer credit report or criminal records check may be necessary prior to my employment. If such reports are required, I understand that, in compliance with federal law, the company will provide me with a written notice regarding the use of these reports and will also obtain a separate written authorization from me to consent to these reports. I also understand that a poor credit history or conviction will not automatically result in disqualification from employment.”

In compliance with federal law, all persons hired will be required to verify identity and eligibility to work in the United States and to complete the required employment eligibility verification document form upon hire.

Applicant Agreement *

I have read and agree to the above terms.

Applicant Signature *

Clear