Employment Application

• * First Name:     Middle Name: 
• * Last Name:     Suffix: 
• *Email Address:
• * Street Address: 
• * City:      * State:      * Zip Code:  
• * Cell/Home Phone:      Other Phone:  

• * Are you under the age of 18?   Yes    No
• For checking records, provide other names under which you are known (place entire name in each field):
• Other Name 1:     Other Name 2: 
• * Are you legally authorized to work in the United States?    Yes    No
• * How?    U.S. Citizen    Visa/Work Permit

• Position Desired:  
• Referred by:
  Newspaper    Employee    Walk-in    Search Engine    Other   
• Shift Desired:    Days    Evenings    Nights   
• Availability:    Full-time    Part-time    PRN    Weekends
• * Have you ever applied for work here before?   Yes    No
• If yes, when?  
• * Have you ever been employed at Providence Healthcare Management?   Yes    No
• If yes, when?  
• * Are you able to perform the required duties of the job you are applying for with or without accomodation?   Yes    No
• If no, please explain:  
• * Do you know anyone currently or previously employed for Providence Healthcare Management?
  Yes    No
• If yes, name and relationship:  

• * Were you ever in the U.S. Armed Forces?  Yes    No
• If yes, what branch?  
• If yes, what dates of duty?    From:       To: 
• * Have you ever been convicted or plead guilty to a criminal offense?
  Yes    No
• If yes, please give details:
  Be sure to record the date of conviction, city & state of conviction, and the offense for each conviction.
  

* Education

• * School Name:       * Level:  Please Select: High School Vocational School College Graduate School
• * Location:      * Graduated?  Yes    No
• * Major/Study Course:      * Diploma/Degree: 

Education

• School Name:       Level:  Please Select: High School Vocational School College Graduate School
• Location:      Graduated?  Yes    No
• Major/Study Course:      Diploma/Degree: 

Education

• School Name:       Level:  Please Select: High School Vocational School College Graduate School
• Location:      Graduated?  Yes    No
• Major/Study Course:      Diploma/Degree: 

Education

• School Name:       Level:  Please Select: High School Vocational School College Graduate School
• Location:      Graduated?  Yes    No
• Major/Study Course:      Diploma/Degree: 

Education

• School Name:       Level:  Please Select: High School Vocational School College Graduate School
• Location:      Graduated?  Yes    No
• Major/Study Course:      Diploma/Degree: 

* Employment

• * Name of Business:       * Phone Number: 
• * Street Address: 
• * City:      * State:      * Zip Code:  
• * Type of Business:      * Position Held: 
• * Reason for Leaving: 
• * Dates of Employment:    * From:       * To: 
• * Describe Duties: 
• * May we Contact?  Yes    No
• If no, please explain:
  

Employment

• Name of Business:       Phone Number: 
• Street Address: 
• City:      State:      Zip Code:  
• Type of Business:      Position Held: 
• Reason for Leaving: 
• Dates of Employment:    From:       To: 
• Describe Duties: 
• May we Contact?  Yes    No
• If no, please explain:
  

Employment

• Name of Business:       Phone Number: 
• Street Address: 
• City:      State:      Zip Code:  
• Type of Business:      Position Held: 
• Reason for Leaving: 
• Dates of Employment:    From:       To: 
• Describe Duties: 
• May we Contact?  Yes    No
• If no, please explain:
  

Employment

• Name of Business:       Phone Number: 
• Street Address: 
• City:      State:      Zip Code:  
• Type of Business:      Position Held: 
• Reason for Leaving: 
• Dates of Employment:    From:       To: 
• Describe Duties: 
• May we Contact?  Yes    No
• If no, please explain:
  

Employment

• Name of Business:       Phone Number: 
• Street Address: 
• City:      State:      Zip Code:  
• Type of Business:      Position Held: 
• Reason for Leaving: 
• Dates of Employment:    From:       To: 
• Describe Duties: 
• May we Contact?  Yes    No
• If no, please explain:
  

Please do not list family members.

• 1.  * Full Name:      * Phone: 
•       * Relationship: 
   
• 2.  * Full Name:      * Phone: 
•       * Relationship: 
   
• 3.  * Full Name:      * Phone: 
•       * Relationship: 

• *    1. I have read the List of Crimes in Senate Bill 160 (Background Checks) and I have not been convicted nor plead guilty to any of those crimes that would disqualify me from working with older adults under S.B. 160.
• *    2. I understand and agree that if I am found to have a record of any of those crimes, whether it be a misdemeanor or felony, I will not be hired to work with older adults, or if I have already been hired, my employment will be terminated.
• *    3. That I was informed that I must provide a set of fingerprint impressions and that a criminal record check must be conducted if I come under final consideration for employment.
• *    4. That the criminal records check does not constitute all of the pre-employment requirements.
• My typed initials and the date, followed by pressing the "Accept and Submit Application" button below, shall attest to the above points, pursuant to the Electronic Records and Signatures in Commerce Act.
  * Initials:        * Date:  

List of Crimes from Ohio Senate Bill 160

In connection with my application for employment, * I understand that investigative background inquiries are to be made including, but not limited to consumer credit, social security number, criminal and motor vehicle records. These reports may contain information about my character, work habits, performance, and experience along with reason for termination of past employments. Furthermore, I understand that information will be requested from various Federal, State and other agencies, which maintain records concerning my personal history. I certify that answers given herein are true and complete to the best of my knowledge, and understand and agree that any misrepresentation or omission on my application or related papers, or made during any oral interviews may result in refusal of employment or shall be considered grounds for dismissal. I understand and agree that, if hired, my employment is at will, for no definite period, and may be terminated at any time without prior notice, without liability for wages, salary or any benefits except those earned up to the date of termination. I understand that this application is NOT, and is not to be intended to be a contract of employment. I understand that I may need to submit additional information upon being considered for employment, and that submitting said additional information does NOT mean that I am hired, or that I will be. I understand, and agree to the above. Typing my name and date below and clicking the "Accept and Submit Application" button signifies my agreement, pursuant to the Electronic Records and Signatures in Commerce Act.

* Full Name:       * Date: 

• Thank you for filling out our employment application. You may attach a resume if you like. Have a good day!
• Attach Resume:   
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