HOLMES COUNTY BOARD OF DD APPLICATION FOR EMPLOYMENT

Holmes County Board of DD welcomes all applicants who are interested in employment with the HCBDD and will ensure that each of you are treated equally in this employment opportunity. The Holmes County Board of DD is an Equal Opportunity Employer. As such, no applicant will be discriminated against because of race, color, religion, creed, age, sex, national origin or ancestry, political affiliation, qualifying disability of for any other reason protected by law. Should it be necessary, applicants are encouraged to request reasonable accommodation in the application/interview process.

Personal Information

First Name *

Last Name *

Address 1 *

Address 2

City *

State *

Zip Code *

Phone *

Email Address *

Are you a Veteran? *

Yes

No

If so, please list your branch of service:

+-

Are you legally permitted to work in the United States? *

Yes

No

Position, Availability and History

Position desired: *

What's your availability? *

Full-Time

Part-Time

Date available to start: *

Have you previously applied for a job with the HCBDD? *

Yes

No

When?

Have you ever been employed by the HCBDD? *

Yes

No

When? Reason for leaving?

Are you related to anyone employed by the HCBDD? *

Yes

No

If yes, state name and relationship:

Have you ever been employed by another public employer in Ohio? *

Yes

No

If yes, provide place and dates of service:

Do you have any time commitments that might interfere with your employment? (e.g. , subject to recall, school) *

Yes

No

If yes, please explain:

Are you able to perform the essential functions of the job(s) for which you are applying with or without reasonable accommodation? (Should there be a question, please refer to the job description.) *

Yes

No

Have you ever been dismissed from or asked to resign from any employment position? *

Yes

No

If yes, please explain:

Pursuant to Ohio Administrative Code Section 5123:2-2-02, The Holmes County Board of Developmental Disabilities is required to conduct background investigations for purposes of employment. Please note that per 5123;2-2-02, there are five tiers of disqualifying offenses with corresponding time periods that preclude an applicant from being employed with this agency. Therefore, all applicants under final consideration will be required to submit to a background check through the Bureau of Criminal Identification and Investigation. For more information, please review OAC 5123:2-2-02. Your signature below verifies only that you understand our requirement to conduct background checks following job offers. Your signature also verifies that you further understand that all prospective employees must pass a drug test prior to being hired.

Signature *

clear

Date: *

If you are applying for a position that requires a driver’s license or a commercial driver’s license to perform the essential duties of the job, please answer the following:

Do you have a valid Ohio driver’s license? *

Yes

No

Do you have a valid Ohio commercial driver’s License with Class B endorsement with S (School Bus) and P (Passenger) endorsement *

Yes

No

Have you been arrested for any traffic-related incidents? *

Yes

No

Has your driver’s license been suspended or revoked within the last three (3) years? *

Yes

No

Have you had your auto insurance rejected, cancelled, or been in a high-risk insurance program? *

Yes

No

Have you been involved in any accident, either at fault or not at fault? *

Yes

No

Have you had any traffic violations in the past three (3) years? *

Yes

No

If yes, please list offense and approximate date/year:

If employed, why do you wish to leave your present employer?

May we contact your present employer for a reference?

Yes

No

Employer’s name and address (if not included elsewhere in this application):

Describe briefly the type of work that you are best qualified to do by reason of background, education, previous employment or training, and tell why you feel qualified for the position(s) for which you are applying: *

Education History

High School

High School name:

Location (city, state, zip):

Major/Subject/Degree:

Scholastic average:

Did you graduate?

Yes

No

College or University

College or University name:

Location (city, state, zip):

Major/Subject/Degree:

Scholastic average:

Did you graduate?

Yes

No

Other school(s) attended?

School name:

Location (city, state, zip):

Major/Subject/Degree:

Scholastic average:

Did you graduate?

Yes

No

Please list any honors received:

Employment History

List all previous employment for the last ten (10) years in chronological order – last position or current employer first – including U.S. Military, if applicable. Attach additional pages if needed or resume if desired.

Employer 1

Company Name

Address

Phone

Start Date +

End Date +

Position

Salary

Supervisor/Manager

Reason for Leaving

May we contact? *

Yes

No

Phone Number

Employer 2

Company Name

Address

Phone

Start Date +

End Date +

Position

Salary

Supervisor/Manager

Reason for Leaving

May we contact? *

Yes

No

Phone Number

Employer 3

Company Name

Address

Phone

Start Date +

End Date +

Position

Salary

Supervisor/Manager

Reason for Leaving

May we contact? *

Yes

No

Phone Number

References

PERSONAL REFERENCES OTHER THAN RELATIVES AND FORMER EMPLOYERS

Reference 1

Name

Title

Email Address

Phone

Reference 2

Name

Title

Email Address

Phone

Reference 3

Name

Title

Email Address

Phone

Please submit a copy of your resume.

Applicants for employment with the HCBDD are evaluated and selected on the basis of individual merit and ability with respect to the position being filled. Applicants are selected and hired without consideration of race, color, religion, sex, age, national origin, political affiliation, sexual orientation, disability or ancestry.

CERTIFICATION

I certify that all information contained in this application is true, complete and correct to the best of my knowledge. I understand that any material omission, misrepresentation or falsification of this information is grounds for dismissal from or refusal of employment. I hereby authorize the investigation of all statements contained in this application and give permission to contact all or any of my previous employers, references and/or schools for information unless otherwise noted in this document, including permission to obtain information related to my prior work history. I also give my consent to contact the Bureau of Motor Vehicles for a Moving Vehicle Violation Report if such information is required to perform the duties of the position. If appropriate for the position, I agree to submit to a post-offer, pre-employment medical examination at the HCBDD’s expense. I understand that I will be required to take a pre-hire drug/alcohol test. I understand that my employment is contingent upon passing the drug/alcohol test and successful completion of the post-offer medical exam, if applicable. I also agree to submit to other specified drug tests, according to the HCBDD’s policy, as a condition of continuing employment. I indemnify and hold harmless all persons either providing or receiving information, verbal or written, pursuant to this application.

Signature *

clear

Date: *