Employment applicationCome and be a part of our growing team. Apply today! 1Personal Info2Education3References4Work History PERSONAL INFORMATIONApplicants for employment with 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 criminal records check will be conducted on all applicants under final consideration for a position with the Ashtabula County Nursing and Rehabilitation Center. Applicants my request reasonable accommodation in the application/interview process.Name* First Middle Last Address* Street Address City State / Province / Region ZIP / Postal Code Telephone*Social Security Number: Please note: This is not a secure form.Application Date Veteran Yes No Branch of Service Are you legally permitted to work in the United States? Yes No PERSONAL INFORMATION CONTINUEDPosition(s) desired: Full Time or Part Time: Full Time Part Time Date available to start Month Day Year Have you previously applied for a job at this facility? Yes No If yes, when: Have you ever been employed at this facility? Yes No If yes, when: Reason for leaving? Are you related to anyone employed at this facility? Yes No State name and relationship: Do you have any time commitments that might interfere with your employment? Yes No If yes, please explain: Have you ever been employed by another public employer in Ohio? Yes No If yes, provide place and dates of service: Have you ever been dismissed from or asked to resign from any employment position? Yes No If yes, provide explain: Have you ever been convicted of a crime (felony or misdemeanor) other than a minor traffic violation: Yes No If yes, where. Please explain. Drivers License/Driving RecordIf 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? Yes No Do you presently have or are you able to obtain a valid Ohio commercial driver's license? Yes No Has your drivers license been suspended or revoked within the last three (3) years? Yes No Have you had any traffic violations in the past three (3) years? Yes No List your offense(s)/List approximate Date/YearIf employed, why do you wish to leave your present employer?May we contact your present employer for a reference? Yes No Describe briefly the type of work which you are best qualified to do by reason of background, education, previous employment or training, and tell why you feel qualified for the position(s) for which you are applying:List any professional licenses/certifications that you hold:List professional organization memberships and office held, excluding those which would indicate race, color, religion, sex, age, national origin, political affiliation, disability and/or ancestry: EDUCATIONAL DATAName of High School City, State, Zip Major/Subject/Degree Scholastic Average Did you Graduate? Yes No Scholastic Average Name of College or University attended City, State, Zip Major/Subject/Degree Scholastic Average Did you Graduate? Vocational Trade Other Other Schools Attended City, State, Zip Major/Subject/Degree Did you Graduate? Vocational Trade Other If others, please specify: Employment DateList all previous employment for the last ten (10) years in chronological order - last position first - including U.S. Military. Attach additional pages if needed or resume if desired.Employer Employer Phone Address Street Address City State / Province / Region ZIP / Postal Code Final/Current Salary Dates Employed From - ToPosition Held Supervisor Reason for leaving Employer Phone Reference Address Street Address City State / Province / Region ZIP / Postal Code Final/Current Salary Dates Employed From - ToPosition(s) Held Supervisor Reason for leaving? Employer Phone Address Street Address City State / Province / Region ZIP / Postal Code Final/Current Salary Dates Employed From - ToPosition(s) Held Supervisor Reason for leaving Residence HistoryAddress Street Address City State / Province / Region ZIP / Postal Code Dates of Residence Address Street Address City State / Province / Region ZIP / Postal Code Dates of Residence Address Street Address City State / Province / Region ZIP / Postal Code Dates of Residence Address Street Address City State / Province / Region ZIP / Postal Code Dates of Residence ReferencesName First Last Address Street Address City State / Province / Region ZIP / Postal Code PhoneOccupation Name First Last Address Street Address City State / Province / Region ZIP / Postal Code PhoneOccupation Name First Last Address Street Address City State / Province / Region ZIP / Postal Code PhoneOccupation CertificationBy signing this form, I sent to the submission of a request for a criminal record check as required by Senate ill 160. The request will be submitted by the Ashtabula County Nursing and Rehabilitation Center. I also attest to the following: (1) that I have not been convicted of 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 those 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 of falsification of this information for grounds for dismissal from or refusal of employment. I hereby authorize the investigation of all statement contained in this application and giver 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 all persons either providing or receiving information, verbal or written, pursuant to this application.Applicant's Signature First Last By filling in your name below, this will count as your legal signature.Date MM slash DD slash YYYY HiddenResume UploadAccepted file types: pdf, Max. file size: 24 MB.Please upload your resume, if any. Δ
