Choices In Community Living, INC.

Application for Employment

An Equal Opportunity Employer

Date*
1651 Needmore Road
Dayton, OH 45414
Phone: (937) 898-2220
Fax: (937) 898-3553
partnersohio.com

General Information

Name*
Address*
Date of birth*
Do you have a high school diploma/GED/ or school transcripts?*
Do you have a valid Ohio Driver's License?*
Do you have a valid proof of car insurance?*
Do you have any physical limitations that would keep you from performing an assigned task, such as lifting or assisting with hoyer lifts?*
How did you hear about us (check all that apply)?*

Page 1

Position

What position are you applying for?*
What type of employment are you applying for?*
Are you able to work the hours from:*
Have you previously applied or been employed by this agency?*
If yes, when?
$
Have you ever been convicted of a crime?*
Were you referred to this position by an existing employee?*

Page 2

Education

Graduated*
Graduated
Graduated
Graduated

Page 3

Employment History

Begin with most recent job

Date Started*
$
$
Address*
May contact this employer
Date Started
$
Address
May contact this employer
Date Started
$
$
Address
May we contact this employer

Page 4

Personal References

Do not include former employers or relatives

Reference #1*
Occupation
Address*
Reference #2*
Occupation
Address
Reference #3*
Occupation
Address

I authorize this agency to conduct an investigation of my application to determine my qualifications for employment. I authorize all persons, educational institutions, corporation, credit bureaus and law enforcement agencies to supply any information on my background to this agency or its agent, and release them from any liability for doing so. I understand that any false or misleading information furnished by me on this application, or in connection with my application for employment, may result in rejection of my application, or if employed by this agency, in the termination of employment. I also understand that as part of the normal employment process, a routine inquiry may be made concerning information as to my character, general reputation and personal characteristics.

Use your mouse or finger to draw your signature above
Date*

Page 5

Attestation and Agreement to Notify Employer

Use your mouse or finger to draw your signature above
Date Signed*
Use your mouse or finger to print your signature above
Tier 1 Disqualifying Offenses (Permanent Exclusion):

A conviction related to fraud, theft, embezzlement, breach of fiduciary responsibility, or other financial misconduct involving a federal or state-funded program, excluding the disqualifying offenses set forth in section 2913.46 of the Revised Code (illegal use of supplemental nutrition assistance program [SNAP] or women, infants, and children [WIC] program benefits).

A violation of an existing or former municipal ordinance or law of this state, any other state, or the United States that is substantially equivalent to any of the offenses or violations on this list.

Tier 2 Disqualifying Offenses (Ten-Year Exclusion):

A violation of an existing or former municipal ordinance or law of this state, any other state, or the United States that is substantially equivalent to any of the offenses or violations on this list.

Tier 3 Disqualifying Offenses (Seven-Year Exclusion):

A violation of an existing or former municipal ordinance or law of this state, any other state, or the United States that is substantially equivalent to any of the offenses or violations on this list.

Tier 4 Disqualifying Offenses (Five-Year Exclusion):

A violation of an existing or former municipal ordinance or law of this state, any other state, or the United States that is substantially equivalent to any of the offenses or violations on this list.

Page 6

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