Online Employment Application

PERSONAL INFORMATION

Name:
(Last)
(First)
(Middle)
Address:
(Street)
(City)
(State)
(Zip)
How long have you lived at this address?
Telephone No.:
Social Security No.:
Previous Address:
How long?
E-Mail Address:
How did you hear about our company?
Phone Book
Current employee
Newspaper
The Internet
Other
Have you ever worked here before?
Yes
No
If so, when and in what position(s)?
Have you ever worked for:
Alois Alzheimer Center
Brookwood Retirement Community
Florence Park
Clovernook Health Care
Loveland Health Care
Covenant Village
Positions applying for:
Rate of pay desired:
Available to work:
Full time
Part Time
Shift preference:
1st
2nd
3rd
Rotating
Will you work different shifts?
Yes
No
Are you currently employed?
Yes
No
Date available to start work?
Are you 18 years of age or older?
Yes
No

PERSONAL REFERENCES

(Give the names of three persons not related to you whom you have known for at least three years)
Name:
Address:
Occupation:
Phone:
Years known:
Name:
Address:
Occupation:
Phone:
Years known:
Name:
Address:
Occupation:
Phone:
Years known:

EDUCATIONAL BACKGROUND

Type of school
Name
Course of Study
Did you graduate?
List Degree or Diploma
High School:
College:
Business or Trade:
Other:

PREVIOUS WORK EXPERIENCE

(List last four positions held - list most recent first)
Name of employer and address (including city, state & zip):
Dates of Employment:
From:
To:
Telephone Number:
Ending Salary:
Job Duties:
Supervisor's Name:
Reason for Leaving:
Name Worked Under:
Name of employer and address (including city, state & zip):
Dates of Employment:
From:
To:
Telephone Number:
Ending Salary:
Job Duties:
Supervisor's Name:
Reason for Leaving:
Name Worked Under:
Name of employer and address (including city, state & zip):
Dates of Employment:
From:
To:
Telephone Number:
Ending Salary:
Job Duties:
Supervisor's Name:
Reason for Leaving:
Name Worked Under:
Name of employer and address (including city, state & zip):
Dates of Employment:
From:
To:
Telephone Number:
Ending Salary:
Job Duties:
Supervisor's Name:
Reason for Leaving:
Name Worked Under:
Please explain all periods of unemployment:
Are there any other experiences, skills or qualifications which you feel especially fit you for work with this facility?

PRE-EMPLOYMENT BACKGROUND PROFILE

Are you known to schools/references/employers by any other name(s)?
Yes
No
If so, please list:
If you have ever been convicted of any of the following (this includes, without limitation, pleading guilty, pleading no contest, or having a finding of guilt) please place check mark next to the conviction.:
2903.01 Aggravated Murder
2907.09 Public Indecency
2913.31 Forgery
2903.02 Murder
2907.12 Felonius Sexual Penetration
2913.4 Medicaid Fraud
2903.03 Voluntary Manslaughter
2907.25 Prostitution
2913.43 Securing Writings by Deception
2903.04 Involuntary Manslaughter
2907.31 Disseminating Matter Harm to Juvenile
2913.47 Insurance Fraud
2903.11 Felonius Assault
2907.32 Pandering Obscenity
2913.51 Receiving Stolen Property
2903.12 Aggravated Assault
2907.321 Pandering Obscenity Involving a Minor
2919.25 Domestic Violence
2903.13 Assault
2907.322 Pandering Sexually Oriented Matter Involving a Minor
2921.36 Prohibition of Conveyance of Certain Items onto Grounds of Detention Facility, Mental Health or MRDD Facility
2903.16 Failing to Provide for a Functionally Impaired Person
2907.323 Illegal Use of Minor in Nudity-Oriented Material or Performance
2923.12 Carrying Concealed Weapons
2903.21 Aggravated Menacing
2911.01 Aggravated Robbery
2923.13 Having Weapons while under Disability
2903.34 Patient Abuse or Neglect
2911.02 Robbery
2923.161 Improperly Discharging Firearm at or into Habitation or School
2905.01 Kidnapping
2911.11 Aggravated Burglary
2925.02 Corrupting Another with Drugs
2905.02 Abduction
2911.12 Burglary
2925.03 Trafficking in Drugs
2905.11 Extortion
2911.13 Breaking & Entering
2925.11 Drug Abuse
2905.12 Coercion
2913.02 Theft, Aggravated Theft
2925.13 Permitting Drug Abuse
2907.02 Rape
2913.03 Unauthorized Use of a Vehicle
2925.22 Deception to Obtain Dangerous Drugs
2907.03 Sexual Battery
2913.04 Unauthorized Use of Property; Unauthorized Access to Computer Systems
2925.23 Illegal Processing of Drug Documents
2907.05 Gross Sexual Imposition
2913.11 Passing Bad Checks
3716.11 Adulterated Food
2907.06 Sexual Imposition
2913.21 Misuse of Credit Cards
2907.07 Importuning
2907.08 Voyeurism
Have you ever been convicted (this includes, without limitation, pleading guilty, pleading no contest or having a finding of guilt) of any misdemeanor or felony not listed above?
Yes
No
If yes, please provide the dates for what and where:
Are you currently:
Accredited
Certified
Licensed
Licensure
or have an interim permit
License/Certification
State of Issuance
Licensing Agency
Expiration Date
Number
If issuing state is not Ohio, have you applied for reciprocity?
Yes
No
Are you eligible for:
Accreditation
Certification
Temporary Permit
Licensure
Registration
If an examination is required, what date are you scheduled to take the exam?
Has your professional license ever been revoked, suspended or subject to any disciplinary action?
Yes
No
If yes, list where, for what and give dates:

Which facilities are you applying to?
Healthcare Management:
Alois Alzheimer Center:
Brookwood Retirement Community:
Florence Park:
Clovernook Health Care:
Loveland Health Care:
Covenant Village: