457 Griswold Road, Elyria, OH 44035 Ph: 440.233.8768 Fax: 440.324.7895 Website: www.myneighborhoodalliance.org 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: ( ) Email 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
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
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 44035 Ph# 440-233-8768, Ext. 6204 Fax# 440-324-7895 Email: pattya@myneighborhoodalliance.org 3
Neighbors helping neighbors since 1927 457 Griswold Road, Elyria, OH 44035 Mail to: P.O. Box 1039, Lorain, OH 44055 Ph: 440.233.8768 Fax: 440.324.7895 Website: www.neighborhood 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#: 440-324-7895 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
Neighbors helping neighbors since 1927 457 Griswold Road, Elyria, OH 44035 Mail to: P.O. Box 1039, Lorain, OH 44055 Ph: 440.233.8768 Fax: 440.324.7895 Website: www.neighborhood 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. 959.13 Cruelty to Animals 2903.01 Murder 2903.02 Voluntary Manslaughter 2903.03 Involuntary Manslaughter 2903.041 Reckless Homicide 2903.11 Felonious Assault 2903.12 Aggravated Assault 2903.13 Assault 2903.15 Permitting child abuse 2903.16 Failing to provide for a functionally impaired person 2903.21 Aggravated menacing 2903.211 Menacing by stalking 2903.22 Menacing by stalking 2903.34 Patient abuse, neglect 2905.01 Kidnapping 2905.02 Abduction 2905.04 Child Stealing 2905.05 Child Enticement 2906.11 Extortion 2907.02 Rape 2907.03 Sexual Battery 2907.04 Corruption of a Minor 2907.05 Gross Sexual Imposition 2907.06 Sexual Imposition 2907.08 Voyeurism 2907.09 Public Indecency 2907.07 Importuning 2907.12 Felonious Sexual Penetration 5
2907.21 Compelling Prostitution 2907.321 Pandering Obscenity Involving a Minor 2907.322 Pandering Sexually Oriented Matter Involving a Minor 2907.323 Illegal Use of a Minor in Nudity- Oriented Material or Performance 2909.02 Aggravated Arson 2909.03 Arson 2909.04 Disrupting Public Services 2909.05 Vandalism 2909.22 Soliciting or Providing Support for Acts of Terrorism 2909.23 Making Terroristic Threat 2909.24 Terrorism 2911.01 Aggravated Robbery 2911.02 Robbery 2911.11 Aggravated Burglary 2911.12 Burglary 2913.02 Theft, Aggravated Theft 2913.03 Unauthorized use of a Vehicle 2913.04 Unauthorized use of property, computer, cable, or telecommunication property or service 2913.041 Possession or sale of unauthorized cable television device 2913.05 Telecommunication Fraud 2913.06 Unlawful use of Telecommunications 2913.11 Passing Bad Checks 2913.21 Misuse of Credit Cards 2913.31 Forgery; Identification Cards 2913.32 Criminal Simulation 2913.33 Making or Using Slugs 2913.40 Medicaid Fraud 2913.41 Prima Facie evidence of purpose to Defraud 2913.42 Tampering with Records 2913.43 Securing Writings by Deception 2913.44 Personating an Officer 2913.441 Law Enforcement Emblem Display 2913.45 Defrauding Creditors 2913.46 Illegal Use of Food Stamps or WIC Program Benefits 2913.47 Insurance Fraud 2913.48 Worker's Compensation Fraud 2913.49 Identity Fraud 2917.01 Inciting to Violence 2917.02 Aggravated Riot 2917.03 Riot 6
2917.31 Inducing a Panic 2917.33 Unlawful Possession or Use of Hoax Weapon of Mass Destruction 2919.12 Unlawful Abortion 2919.121 Performing or Inducing Unlawful Abortion upon a Minor 2919.13 Abortion Manslaughter 2919.22 Endangering Children 2919.23 Interference of Custody if a violation of this statue (RC 2919.23) would of have been 2905.4 before 7/1/96 2919.24 Contributing to Unruliness or Delinquency of a Child 2919.25 Domestic Violence 2921.02 Bribery 2921.03 Intimidation 2921.04 Intimidation of Attorney, Victim or Witness in Criminal Case. 2921.05 Retaliation 2921.11 Perjury 2921.13 Falsification 2921.34 Escape 2921.35 Aiding Escape or Resistance to Authority 2921.41 Theft in Office 2923.01 Conspiracy 2923.02 Attempt that relates to a crime specified in division 109.572 (A) (9) 2923.03 Conspiracy that relates to a crime specified in division 109.572 (A) (9) 2923.12 Carrying a Concealed Weapon 2923.13 Having a Weapon while under a Disability 2923.161 Improperly Discharging Firearm At or Into Habitation or School -Related Offenses 2923.17 Unlawful Possession of Dangerous Ordinance; Illegally Manufacturing or or Processing Explosives 2923.21 Improperly Furnishing Weapons to a Minor 2925.02 Corrupting another with Drugs 2925.03 Trafficking in drugs 2925.04 Illegal manufacture of Drugs or Cultivation of Marijuana 2925.05 Funding of Drug or Marijuana Trafficking 2925.06 Illegal Administration or Distribution of Anabolic Steroids 2925.11 Possession of Drugs or Marijuana that is not a minor Drug Possession offense in section R.C. 2925.01 2927.12 Ethnic Intimidation 3716.11 Placing Harmful Objects in Food or Confection 4511.19 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