Employment Application

Applicant Information

Your Name

Date of Birth

Your Address

City

State/Province

Zip/Postal

Your Phone

Your Email

Referred by

Position(s) Applied for

Rate of pay expected $ per hour

Date Available

Shift Preference

Do you prefer full time or part time

Full Time

Part Time

Education

School Type

High School

College

OtherOther

School Name

School Address

Years Completed

1

2

3

4

Describe Course of Study Or Special Training

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More About You

Do you have any special skills and/or training relevant to the job for which you are applying?

Yes

No

If yes, what?

Have you ever applied with us before?

Yes

No

If yes, when?

Have you ever worked under any other name? (Maiden name, etc.)

Yes

No

If yes, what?

Are you older than 18 years old?

Yes

No

If no, do you have a work permit?

Yes

No

Do you have any licenses and/or certifications relevant to the job for which you are applying?

Yes

No

If yes, provide type and issuing agency

Have you ever been fired, dismissed, or asked to resign from any job?

Yes

No

If yes, which employer and why?

Are you or have you ever been licensed or certified in another state?

Yes

No

If yes, when and where?

References

(Please list three professional references.)

Reference Name

Relationship

Reference Phone

Reference Company

Address

City

State/Province

Zip/Postal

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Previous Employment

List all present and past employments, beginning with your most recent position.

Previous Company Name

Type of Business

Company Phone Number

Supervisor Name

May we contact your previous supervisor for a refernece?

Yes

No

Company Address

City

State/Province

Zip/Postal

Job Title

From

To

Starting Salary

Ending Salary

Describe the work you performed

Reason for Leaving

Add a Job Remove

Resume

Upload Your Resume and Cover Letter Here

Maximum file size: 20MB

Disclaimer and Signature

I understand that

my background and references will be checked and I hereby authorize Good Shepherd Home to investigate all statements made in this application as necessary, and to contact any person or entity identified in this application in order to obtain information about me, my education, and my prior job performance. By signing below, I hereby release Good Shepherd Home, including any and all of its officers, directors, managers, and employees, from any and all liability and or damages relating to or arising from such background investigation.

I understand that

This application for employment shall be considered active for a period of 45 days.

I understand that

if I am offered employment at Good Shepherd Home, there is no guarantee that I will be offered the position and or shift preference indicated, and that the shift, working hours, or duties can be changed from time to time due to changes in management policy or procedure.

I understand that

All licenses and or certifications (e.g., State Tested Nursing Assistants or Licensed Nurses) must be current, unencumbered, and in good standing to work at Good Shepherd Home.

I understand that

The employment application is not a contract of employment. I hereby understand and acknowledge that, except as provided by applicable law, or a governing collective bargaining agreement, any employment relationship with Good Shepherd Home is of an “at will “nature. This means that either Good Shepherd Home or the employee may terminate the employment relationship at any time and for any lawful reason.

I Consent

to the submission of a request submitted by Good Shepherd Home for criminal records check for long term care workers as required by Senate Bill 160 (i.e., Ohio Revised Code §3721.121).

I hereby attest that I:

Have not been convicted of, or pleaded guilty of, any of the crimes that would disqualify me from working with older adults under SB 160 even if the conviction has been sealed and/or expunged.

I hereby attest that I:

Understand and agree that if I am found to have a record or conviction of any of these crimes, I will not be hired for work with older adults or, if I have already been hired, my employment will be terminated.

I hereby attest 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 of employment.

In the event of my employment, I understand that

any false or misleading information on my application or interview(s) may result in termination of my employment. I also understand that, as a condition of my continued employment with Good Shepherd Home, I am required to abide by all applicable rules and regulations of the Home.

I hereby attest that I:

have never been debarred, or otherwise excluded from participation in a federal or state healthcare program (Medicare, Medicaid, etc.)

Applicant Signature

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Date