EMPLOYMENT APPLICATION PERSONAL INFORMATION

Transcription

1 457 Griswold Road, Elyria, OH Ph: Fax: Website: EMPLOYMENT APPLICATION PERSONAL INFORMATION Date: / / Position Applying For: Name: Social Security #: Last First MI Home Address: Number Street Apt # ( ) City State Zip Day Phone Evening Phone: ( ) Address: How did you hear of us? When can you start? Have you ever been employed by Neighborhood Alliance? No Yes If yes, What Center What Program When Have you ever volunteered/worked through another agency at one of our Centers? No Yes If yes, What Agency What Program When Do you have any family members working for us? No Yes If yes, what department? Employee Name _ Can you speak any language other than English? No Yes If Yes, please list languages spoken: EDUCATION INFORMATION High School: Year Graduated: College/Trade School: # of Years Attended Year Graduated Major: College/Trade School: # of Years Attended Year Graduated Major: 1

2 EMPLOYMENT INFORMATION (Please list the most recent first) **IF YOU HAVE A RESUME, PLEASE ATTACH** Company Name: Phone Number: Supervisor s Name: Job Duties: Dates Employed: From: to Reason for Leaving: Company Name: Phone Number: Supervisor s Name: Job Duties: Dates Employed: From: to Reason for Leaving: Company Name: Phone Number: Supervisor s Name: Job Duties: Dates Employed: From: to Reason for Leaving: Name: EMPLOYMENT REFERENCES Company Name: Phone Number: ( ) Length of Time Known: Name: Company Name: Phone Number: ( ) Length of Time Known: Name: Company Name: Phone Number: ( ) Length of Time Known: (PLEASE PROVIDE THREE WORK RELATED REFERENCES) 2

3 Background Information NOTICE: Neighborhood Alliance is required to conduct a criminal background investigation on all employees. 1. Have you ever been convicted of a criminal offense? Yes No If Yes to any of the above, please explain: Number of Incidents? Nature of Incident(s)? Date(s) of Incident(s)? Resolution PLEASE READ AND UNDERSTAND THE POINTS BELOW BEFORE SIGNING: I understand that: I certify that the information provided is accurate and that inaccurate information will result in employment termination if I am hired. I hereby authorize any person to release any information about me concerning my suitability to act as a NEIGHBORHOOD ALLIANCE employee as such person deems relevant in his or her sole discretion. I affirm that I have read and understand the above information and that the information I have given NEIGHBORHOOD ALLIANCE is accurate and complete. Applicant Name (please print): Applicant Signature: Date: / / Neighborhood Alliance is committed to the principle and practice of equal employment opportunity. No person because of race, color, national origin, religion, gender, sexual orientation, age, handicap, or other non-merit factors shall be discriminated against in employment or in any way be excluded from participation in, or be denied the benefits of any program or activity in this Association. THANK YOU FOR TAKING THE TIME TO COMPLETE THIS APPLICATION. WE LOOK FORWARD TO WORKING WITH YOU. Please return completed form to: Neighborhood Alliance 457 Griswold Road, Elyria, OH Ph# , Ext Fax# pattya@myneighborhoodalliance.org 3

4 Neighbors helping neighbors since Griswold Road, Elyria, OH Mail to: P.O. Box 1039, Lorain, OH Ph: Fax: Website: Alliancelorain.org WORK RELATED REFERENCE I,, give my consent on to NEIGHBORHOOD ALLIANCE and the person listed below as a job related reference to release any information regarding my previous and/or present employment. I am also authorizing the below questions to be answered, which are in reference to myself or any position that is offered to me at Neighborhood Alliance. Return to: Administrative Offices Personnel Office Fax#: Dear : Mr./Ms. has applied for the position of You have been listed as a reference by the above named individual. Please comment briefly on the following that may apply to you as a designated reference. Applicant s employment dates with you: from to. Reason applicant left: Position/Title: Responsibilities/Duties: Significant Achievements at work: Using ONE of the numbers listed below, please indicate the perspective employees rating: 0 = NOT 1 = OUTSTANDING 2 = ABOVE STANDARD 3 = STANDARD 4 = NEEDS IMPROVEMENT 5 = VERY POOR Dependability: ; Cooperation: ; Initiative: ; Flexibility: ; Ability to work with other staff: ; Ability to Supervise: What were the employee s weaknesses? Additional Comments: (Signature & Title of person giving reference) / / 4 Date

5 Neighbors helping neighbors since Griswold Road, Elyria, OH Mail to: P.O. Box 1039, Lorain, OH Ph: Fax: Website: Alliancelorain.org Disqualifying Offenses for Employment, Volunteer Services or Community Service Neighborhood Alliance appreciates your interest in employment, providing volunteer services and/or community service hours to our Agency. However, due to State and Federal regulations and NEIGHBORHOOD ALLIANCE Policy, you must undergo a criminal background investigation. If you have been convicted of or pleaded guilty to a violation of any of the following sections of the revised code or similar offenses, we cannot utilize you in the capacity of providing services to our participants. We appreciate your interest in our Agency Cruelty to Animals Murder Voluntary Manslaughter Involuntary Manslaughter Reckless Homicide Felonious Assault Aggravated Assault Assault Permitting child abuse Failing to provide for a functionally impaired person Aggravated menacing Menacing by stalking Menacing by stalking Patient abuse, neglect Kidnapping Abduction Child Stealing Child Enticement Extortion Rape Sexual Battery Corruption of a Minor Gross Sexual Imposition Sexual Imposition Voyeurism Public Indecency Importuning Felonious Sexual Penetration 5

6 Compelling Prostitution Pandering Obscenity Involving a Minor Pandering Sexually Oriented Matter Involving a Minor Illegal Use of a Minor in Nudity- Oriented Material or Performance Aggravated Arson Arson Disrupting Public Services Vandalism Soliciting or Providing Support for Acts of Terrorism Making Terroristic Threat Terrorism Aggravated Robbery Robbery Aggravated Burglary Burglary Theft, Aggravated Theft Unauthorized use of a Vehicle Unauthorized use of property, computer, cable, or telecommunication property or service Possession or sale of unauthorized cable television device Telecommunication Fraud Unlawful use of Telecommunications Passing Bad Checks Misuse of Credit Cards Forgery; Identification Cards Criminal Simulation Making or Using Slugs Medicaid Fraud Prima Facie evidence of purpose to Defraud Tampering with Records Securing Writings by Deception Personating an Officer Law Enforcement Emblem Display Defrauding Creditors Illegal Use of Food Stamps or WIC Program Benefits Insurance Fraud Worker's Compensation Fraud Identity Fraud Inciting to Violence Aggravated Riot Riot 6

7 Inducing a Panic Unlawful Possession or Use of Hoax Weapon of Mass Destruction Unlawful Abortion Performing or Inducing Unlawful Abortion upon a Minor Abortion Manslaughter Endangering Children Interference of Custody if a violation of this statue (RC ) would of have been before 7/1/ Contributing to Unruliness or Delinquency of a Child Domestic Violence Bribery Intimidation Intimidation of Attorney, Victim or Witness in Criminal Case Retaliation Perjury Falsification Escape Aiding Escape or Resistance to Authority Theft in Office Conspiracy Attempt that relates to a crime specified in division (A) (9) Conspiracy that relates to a crime specified in division (A) (9) Carrying a Concealed Weapon Having a Weapon while under a Disability Improperly Discharging Firearm At or Into Habitation or School -Related Offenses Unlawful Possession of Dangerous Ordinance; Illegally Manufacturing or or Processing Explosives Improperly Furnishing Weapons to a Minor Corrupting another with Drugs Trafficking in drugs Illegal manufacture of Drugs or Cultivation of Marijuana Funding of Drug or Marijuana Trafficking Illegal Administration or Distribution of Anabolic Steroids Possession of Drugs or Marijuana that is not a minor Drug Possession offense in section R.C Ethnic Intimidation Placing Harmful Objects in Food or Confection Operating Vehicle under the Influence of Alcohol or Drugs OVI; A second Violation within Five Years of the date of Application for Licensure/employment. 7