Applicant Information (* required)
Are you a citizen of the United States?* Yes No
If no, are you authorized to work in the U.S.? Yes No
Have you ever worked for this company?* Yes No
If so, when?
Have you ever been convicted of a felony?* Yes No
If yes, explain
Did you graduate? Yes No
References (Please list three professional references)
May we contact your previous supervisor for a reference? Yes No
May we contact your present supervisor for a reference? Yes No
If other than honorable, explain
Disclaimer and Printed Signature
I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.
PLEASE READ CAREFULLY
I have not been convicted of or pleaded guilty to a disqualifying offense as listed or described in divisions (A) (3) (a) to (A) (3) C of Section 109.572 of the Revised Code.
I agree to notify the residential facility within fourteen calendar days, if, while employed by the residential facility, I have been formally charged with, is convicted of, or pleaded guilty to a disqualifying offense. Failure to make the notification may result in termination of my employment.