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Name *

First

Last

Date of birth *

Phone Number *

Last 4 of SSN - This is for background check *

Address - City, State, Zip Code *

Address Continued

How were you referred to company? *

What positions are you applying for? *

Available hours for work? *

Full-time
Part-time
Anything available

What days are you available to work?

***Please not that all staff is required to work atleast every other weekend. If you are not available/willing to work everyother weekend, you will not be considered for employment***

Are you available to work at least every other weekend *

List the times of the day you are available to work *

Salary desired? *

If hired, what date can you start? *

Do you have any friends, relatives, or acquaintances working for Kentix Developmental Health *

If so, state name and relationship *

Do you have any friends, relatives, or acquaintances that receive services from Kentix Developmental Health *

Do you have your own car/and willing to transport clients? *

Do you have a valid driver's license with less than 4 points? You will not be considered for employment if your drivers license is NOT valid with 4 points or less! *

Do you have valid proof of automobile insurance? You will not be considered for employment if you do NOT have insurance! *

Are you over 18 years of age? *

If hired, would you be able to present evidence of your U.S. citizenship or proof of your legal right to work in the United States? *

Have you resided in Ohio for the past 5 years? *

If considered for employment, are you willing to submit to and pass a controlled substance test? *

Do you have any medical conditon that will prevent you from performing your duties while at work? *

If yes, please explain

Are you able to perform the essential functions of the job for which you are applying, either with/without reasonable accommodation? *

If no, describe the functions that cannot be performed

Are you CPR certified? *

Are you certified to pass medication? *

(Note: Kentix Developmental Health complies with the ADA and consider reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. It is possible that a hire may be tested on skill/agility and may be subject to a medical examination conducted by a medical professional.) *

Type yes if you understand

Have you ever been charged/convicted of a criminal offense (felony or misdemeanor)? This includes traffic offenses. *

If yes, please describe the crime - state nature of the crime(s), when and where convicted and disposition of the case.

No applicant will be denied employment solely on the grounds of conviction of a ciminal offense. The date of the offense, the nature of the offense, including any significant details that affect the description of the event, and the surrounding circumstances and the relevance of the offense to the position applied for may, however, be considered

Type yes if you understand

College/University/Vocational School - School name, address, Number of years complete, did you graduate, degree or diploma. Please type all that in the box, after each field hit enter to put next field answer on the next line, ex type school name first and hit enter, address then enter and so on. If you did not attend any of those schools please type DID NOT ATTEND *

High School - School name, address, Number of years complete, did you graduate, degree or diploma. Please type all that in the box, after each field hit enter to put next field answer on the next line, ex type school name first and hit enter, address then enter and so on *

Previous Employment, most recent first. - Company name *

Address *

Date started/ended *

Job Title *

Reason for leaving *

Immediate Supervisor *

Phone Number *

Is it ok to contact this employer? *

Next Employer - Company Name

Address

Date started/ended

Job Title

Reason for leaving

Immediate Supervisor

Phone Number

Is it ok to contact this employer?

Applicant's Statement - Kentix Developmenal Health selects the best matched individual for the job based upon job related qualifications, regardless of race, creed, sex, national origin, age, handicap, or other protected groups under federal, state or local Equal Opportunity Laws.------------------------------------------------------------------------------------- A satisfactory criminal background check, driving record report and drug screen wil be required prior to employment. I certify that answers given herein are are true and complete to the best of my knowledge. ------------------------------------ I give permission/authorization for an investigation of all statements contained in this application for employment necessary in arriving at an employment decision. This includes providing a set of fingerprint impressions for the required criminal background check and giving consent to perform a required drug screen. -------------------------------------------- I hereby understand and acknowledge that, unless otherwise defined be applicable law, any employment relationship with this organization is of an "at-will" nature, which means that an employee may resign at anytime, and the employer may discharge the employee at any time with or without cause. It is further understood that this at will employment relationship may not be changed by any written document or by conduct unless an executive of this organization specifically acknowledges such a change in writing. -------------------------------------------------------------------------------------------- In the event of employment, I understand that false or misleading information given in my application or interview may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.

Type yes if you understand

Name - Electronic Signature *

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Last

Date

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