Personal Information
Position Applied For (*)
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Name (*)
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Address (*)
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City (*)
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State (*)
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Zip (*)
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Social Security Number (*)
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Primary Phone Number (*)
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Email (*)
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Secondary Phone Number
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Selective Service Number and Classification
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Emergency Contact Name
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Employment Information
Emergency Contact Phone Number
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Are you available to work?
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Shift Availability
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Date Available (*)
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Are you available to work overnights? (*)
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Hourly Rate Expected (*)
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Have you been shown a copy of the job description listing the essential functions of the job? (*)
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Can you perform these essential functions with reasonable accommodation (*)
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How did you learn of this opening?
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Are you available to work shifts? (*)
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Are you available to work overtime? (*)
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Are you available to work weekends? (*)
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Do you have a valid driver's license? (*)
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Do you have transportation available full time? (*)
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Have you worked for this Agency before? (*)
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Have you applied for this Agency before? (*)
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Have you ever been convicted of a crime? (*)
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If yes, explain conviction (s)
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List date (s) of all conviction (s)
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Probation Status
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Disclosure of a criminal record will not necessarily disqualify you for employment. Each conviction will be evaluated on its own
merits with respect to time, circumstances and seriousness of the offense in relation to the job for which you are applying.
Education and Training
High School
Name
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State
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City
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Graduated
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Type of Degree
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Undergraduate School
Name
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City
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State
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Diploma
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Deg/Cert/Dip
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Area of Study
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Other Training
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Please explain why you are seeking this position
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Additional information
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References
Reference 1
Name (*)
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Address (*)
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Phone (*)
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Relationship (*)
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Reference 2
Name (*)
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Address (*)
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Phone (*)
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Relationship (*)
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Reference 3
Name (*)
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Address (*)
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Phone (*)
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Relationship (*)
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Employment Experience
Employer
Employer
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Address
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Phone
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Position Held
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From (mm/yyyy)
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To (mm/yyyy)
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Pay Upon Leaving
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Supervisor
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Duties
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Reason For Leaving
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Prior Employer (1)
Employer
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Address
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Phone
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Position Held
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From (mm/yyyy)
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To (mm/yyyy)
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Pay Upon Leaving
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Supervisor
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Duties
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Reason For Leaving
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Prior Employer (2)
Employer
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Address
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Phone
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Position Held
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From (mm/yyyy)
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To (mm/yyyy)
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Pay Upon Leaving
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Supervisor
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Duties
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Reason For Leaving
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Resume
Upload Resume (*)
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OHIO REVISED CODE
Section
- 2903.01 Aggravated Murder
- 2903.02 Murder
- 2903.03 Voluntary Manslaughter
- 2903.04 Involuntary Manslaughter
- 2903.11 Felonious Assault
- 2903.12 Aggravated Assault
- 2903.13 Assault
- 2903.16 Failing to Provide for Functionally Impaired Person
- 2903.21 Aggravated Menacing
- 2903.34 Patient Abuse or Neglect
- 2903.341 Patient Endangerment
- 2905.01 Kidnapping
- 2905.02 Abduction
- 2905.05 Criminal Child Enticement
- 2907.02 Rape
- 2907.03 Sexual Battery
- 2907.04 Corruption of a Minor
- 2907.05 Gross Sexual Imposition
- 2907.06 Sexual Imposition
- 2907.07 Importuning
- 2907.08 Voyeurism
- 2907.09 Public Indecency
- 2907.12 Felonious Sexual Penetration
- 2907.21 Compelling Prostitution
- 2907.22 Promoting Prostitution
- 2907.23 Procuring
- 2907.25 Prostitution
- 2907.31 Disseminating Matter Harmful Juveniles
- 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 a Minor in Nudity-Oriented Material or Performance
- 2911.01 Aggravated Robbery
- 2911.02 Robbery
- 2911.11 Aggravated Burglary
- 2911.12 Burglary
- 2919.12 Abortion without Informed Consent
- 2919.22 Endangering Children
- 2919.24 Contributing to Unruliness or Delinquency
- 2919.25 Domestic Violence
- 2923.12 Carrying a Concealed Weapon
- 2923.13 Possessing Firearm in Liquor Permit Premises
- 2923.161 Improperly Discharging Firearm at or into Habitation or School
- 2925. 02 Corrupting Another with Drugs
- 2925.03 Drug Trafficking Offenses
- 2925.04 Illegal Manufacturing of Drugs and Cultivation of Marijuana
- 2925.05 Funding of Drug and Marijuana Trafficking
- 2925.06 Illegal Administration or Distribution of Anabolic Steroids
- 2925.11 Drug Abuse / Possession of Drugs
- 3716.11 Adulteration of food
I, the undersigned job applicant, solemnly swear and affirm that I have not been convicted, or pled guilty to any of the above listed
offenses. Furthermore, I agree to notify this agency within fourteen calendar days if, while employed by this agency, I am formally
charged with, convicted of, or plead guilty to any of the above listed offenses. Failure to report formal charges, a conviction, or a
guilty plea may result in being dismissed from employment.
(*)
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APPLICANT'S AGREEMENT
If necessary, I will take courses required by the Ohio Department of Education and / or The Ohio Department of Developmental Disabilities. I understand that these may be college courses and that I may be responsible for payment.
I have read all sections of this application and certify that all the statements made in this application are true and correct to the best
of my knowledge and belief. I understand and agree that the discovery of any false information provided or any relevant information
omitted (no matter when discovered) may result in the refusal to hire me or the termination of my employment, at the discretion of
the Administrator.
I authorize and instruct Residential Concepts, Inc. to make whatever inquiries it considers necessary of any person or organization,
which is not a consumer reporting agency, to verify any of the information I have provided in this application and to determine my
qualifications and abilities. In exchange for Residential Concepts, Inc.'s agreement to receive process and consider my application
for employment, I hereby release Residential Concepts, Inc. of any and all claims and causes of action rising out of the Residential
Concepts, Inc.'s efforts to verify the information I have provided in this application and / or its determination of my qualifications
and abilities.
It is my understanding that Residential Concepts, Inc. will make a thorough investigation of my entire work history and may verify
all data given in my application for employment, related papers, or oral interviews. I authorize such investigation and the giving and
receiving of any information requested by Residential Concepts, Inc. and I release from liability any person giving or receiving any
such information. I understand that falsification of data so given or other derogatory information discovered as a result of this
investigation may prevent me from being hired, or if hired, may subject me to immediate dismissal.
I further understand that this is an application for employment and that no employment contract is being offered.
I understand that if I am employed, such employment is for no definite period of time and that Residential Concepts, Inc. can
change wages, benefits, and conditions at any time.
I am prepared to offer documentation of my right to work in the United States.
I have read and understand the above information and certify that the information I have provided on this application is accurate to
the best of my knowledge.
(*)
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I have not pled guilty to or been convicted of a felony or first degree misdemeanor which bears direct and substantial relationship to
the position for which I am applying. I understand and agree to the conduct of a criminal background check, the results of which are
not public record, a copy shall be provided to me. I further understand and agree to the conduct of a motor vehicle driving
abstract, a Nurse's Aide Registry check and an Abuser Registry check from the Ohio Department od Developmental Disabilities, copies of which shall be provided to me.
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