Application for Employment

Applicants for employment with the Ashtabula County Nursing and Rehabilitation Center are evaluated and selected on the basis of individual merit and ability with respect to the position being filled. Applicants are selected and hired without discrimination based on race, color, religion, sex, age, national origin, political affiliation, disability or ancestry. Fingerprinting and a criminal background check will be conducted on all applicants under final consideration for a position with the Ashtabula County Nursing and Rehabilitation Center. Applicants may request reasonable accommodation in the application/interview process. 

Personal Data
Name
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Maiden Name
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Address
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Phone --
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E-mail
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Position Desired
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Date Available to Start //
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Have you ever been convicted of a crime (felony or misdemeanor) other than a minor traffic violation?
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If yes, please explain.
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Work History
Have you ever previously applied for a job at this facility?
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If yes, when?  
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Have you ever been employed by this facility?
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If yes, when?  
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Have you ever been employed by another public employer in Ohio?
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If yes, where?
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Have you ever been dismissed from or asked to resign from any employment position?
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If yes, please explain.
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Employment History
List your two most recent places of employment in chronological order - last position first. Include the U. S. Military. If a required field does not apply to you, please type N/A.
Current/Most Recent Employer
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Address
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Supervisor
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Phone --
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Position Held
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Final/Current Salary
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Dates Employed  
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Dates Employed  
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Reason for Leaving
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Second Most Recent Employer
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Address
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Supervisor
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Phone --
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Position Held
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Final Salary
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Dates Employed  
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Dates Employed  
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Reason for Leaving
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Educational Data
High School
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Did you graduate from high school?
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College/University
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Did you graduate?
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Major/Degree
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Other Schools Attended
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Other Professional Licenses/Certifications
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Driving History
If the job posting listed a driver's license or commercial driver's license as required for the job, please answer the following.
Do you have a valid Ohio Driver's License?
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Do you currently have or are you able to obtain a valid Ohio Commercial Driver's License?
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Has your Driver's License been suspended or revoked within the last three years?
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Have you had any traffic violations in the last three years?
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Attach Resume
Resume
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Please attach your resume here
Certification
By signing this form, I consent to the submission or a request for a background check as required by Senate Bill 160. The request will be submitted by Ashtabula County Nursing and Rehabilitation Center. I also attest to the following: (1) that I have not been convicted or pleaded guilty to any of the crimes that would disqualify me from working at the Ashtabula County Nursing and Rehabilitation Center under S.B. 160; (2) that I understand and agree that if I am found to have a record of any of these crimes, I will not be hired for work at the Ashtabula County Nursing and Rehabilitation Center, or if I have already been hired, my employment will be terminated; and (3) that I was informed that I must provide a set of fingerprint impressions and that a criminal records check must be conducted if I come under final consideration for employment. I certify that all information contained in this application is true, complete and correct to the best of my knowledge. I understand that any material omission, misrepresentation or falsification of this information is grounds for dismissal or refusal of employment. I hereby authorize the investigation of all statements in this application and give permission to contact all or any of my previous employers, references and/or schools for information unless otherwise noted in this document. I also give my consent to contact the Bureau of Motor Vehicle Violation Report if such information is required to perform the duties of the position. I indemnify and hold harmless all persons either providing or receiving information, verbal or written, pursuant to this application.
Applicant's Signature
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Today's Date //
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