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PLEASE NOTE, DUE TO THE NATURE OF OUR BUSINESS, YOU MUST BE AT LEAST 16 YEARS OF AGE TO BE ELIGIBLE FOR EMPLOYMENT

LAST NAME:		SOC. SEC. NUMBER:
FIRST NAME:
M.I.:		HOME PHONE:
HOME ADDRESS:
COUNTY:		* EMAIL ADDRESS:
CITY:		* We must have your e-mail address to reply to you!
STATE:
ZIP:

POSITION SOUGHT:		DESIRED SHIFT:	1st 2nd 3rd 4th
WILLING TO WORK: Full-time Part-time Weekends Summer Only Temporary On-call

HAVE YOU EVER BEEN EMPLOYED IN THE STATE OR COUNTY SERVICE OF OHIO?		Yes No
IF YES, WHERE?	UNDER WHAT NAME?
DEPARTMENT:	Start Date:	Date Left:

DO YOU POSSESS A VALID DRIVER’S LICENSE?		Yes No
IF YES - TYPE OF LICENSE:		NUMBER:

ARE YOU ELIGIBLE TO WORK IN THE UNITED STATES?	Yes No
HAVE YOU EVER BEEN CONVICTED OF A CRIME?	Yes No
IF YES, PLEASE EXPLAIN: (The employer will only consider specific crimes related to qualifications for positions applied for.)
IF YOU ARE APPLYING FOR A ‘DIRECT CARE POSITION’, ARE YOU WILLING TO SUBMIT TO A STATE AND/OR FEDERAL CRIMINAL BACKGROUND CHECK? Yes No

EMPLOYMENT HISTORY AND WORK EXPERIENCE

CURRENT EMPLOYER:	(Enter "NONE" if unemployed)
MAY WE CONTACT YOUR CURRENT EMPLOYER PRIOR TO EMPLOYMENT?		Yes No
ADDRESS :
ADDRESS2 :
City, State Zip :
Employer Phone# :

DATE STARTED EMPLOYMENT:
JOB TITLE:
SUPERVISOR’S NAME:

BEGINNING SALARY: PER CURRENT SALARY: PER
DESCRIBE YOUR DUTIES, RESPONSIBILITIES, EQUIPMENT OPERATED, PROMOTIONS, ETC.:

WHY DO YOU WANT TO LEAVE?
NUMBER OF PEOPLE YOU SUPERVISED?

Previous Employer Information

PREVIOUS EMPLOYER :
ADDRESS :
ADDRESS 2 :
CITY, STATE ZIP :
PHONE NUMBER:

DATES EMPLOYED: TO

JOB TITLE: SUPERVISOR’S NAME:

BEGINNING SALARY: PER ENDING SALARY: PER

DESCRIBE YOUR DUTIES, RESPONSIBILITIES, EQUIPMENT OPERATED, PROMOTIONS, ETC.:

WHY DID YOU LEAVE?

NUMBER OF PEOPLE YOU SUPERVISED?

EDUCATION AND TRAINING

This section is intended to give the employer information about the education and training that the applicant has complete, and to demonstrate the skills, knowledge, and abilities of the applicant to perform the job duties of the position.

HIGH SCHOOL ATTENDED

DID YOU GRADUATE? Yes No

IF NO: HIGHEST GRADE LEVEL ACHIEVED?

DO YOU HAVE HIGH SCHOOL EQUIVALENT? Yes No

COURSES PERTAINING TO JOB APPLIED FOR:

ACTIVITIES, AWARDS, SPORTS, ETC.:

COLLEGE OR TRADE SCHOOL ATTENDED:

ADDRESS:

DATES OF ATTENDANCE: TO

DID YOU GRADUATE? Yes No DEGREE:

COURSES PERTAINING TO JOB APPLIED FOR:

GRADUATE SCHOOL(S) ATTENDED:

ADDRESS:

DATES OF ATTENDANCE: TO

DID YOU GRADUATE? Yes No DEGREE:

Please use the following space to provide any further information on training, education, skills, abilities, hobbies, volunteer work, etc., that you posses or have experienced that may be helpful in the evaluation of your application:

CERTIFICATION / LICENSURE DATA

PLEASE COMPLETE, IF APPLICABLE: (NOT DRIVERS LICENSE)

	Type	Number	State
CERTIFICATION
REGISTRATION
LICENSURE
INTERIM PERMIT

Continued....
	Date/Year	Issued	Exp. Date
CERTIFICATION
REGISTRATION
LICENSURE
INTERIM PERMIT

PERSONAL INFORMATION

DO YOU HAVE ANY COMMITMENTS (I.E., SECOND JOB, SCHOOL, ETC.) WHICH MIGHT INTERFERE WITH, OR ADVERSELY AFFECT YOUR EMPLOYMENT, SHOULD WE SELECT YOU FOR A POSITION? Yes No

IF YES, PLEASE EXPLAIN:

DO YOU HAVE ANY RELATIVES OR FRIENDS WORKING FOR FAIR HAVEN SHELBY COUNTY HOME?
Yes No

IF YES, PLEASE LIST BELOW:

Name	Relationship to you

Please be advised that filling out this application and clicking the "Submit" button below authorizes us to ask for personnel, academic and other related records from sources listed above. We are also authorized to investigate any information provided. Any misrepresentation or falsification of information may lead to withdrawal of any employment offer or termination following employment.