Applicant Information Middle Initial Address * Phone Number * Email * First position for which you are applying: * Second position for which you are applying: * Shifts you are willing to work * Can you safely perform the essential functions of the position for which you are applying? * If no, please explain: Have you ever been discharged or requested to resign from a position? * If yes, please explain: Have you ever been employed by the State of Ohio or the County of Lorain? * If yes, please explain: Do you currently receive pay to provide services to one or more persons with disabilities? * If yes, please explain: Are you employed at the present time? * Can you accept a position immediately? * Education High School Name High School Location College/University Name & Location College/University Academic Major/Area of Study Level of Degree Graduate School Name & Location Graduate School Academic Major/Area of Study Level of Degree Summarize other related training, skills, or qualifications: Employment History
Provide your employment history beginning with most recent first • A resume may NOT be used as a substitution for completing
Previous Employer #1 Position Held Address (City, State, Zip) Phone (area code) Supervisor Name/Title Start Date End Date Major Responsibilities Reason for Leaving Ending Wage Previous Employer #2 Position Held Address (City, State, Zip) Phone (area code) Supervisor Name/Title Start Date End Date Major Responsibilities Reason for Leaving Ending Wage Previous Employer #3 Position Held Address (City, State, Zip) Phone (area code) Supervisor Name/Title Start Date End Date Major Responsibilities Reason for Leaving Ending Wage Previous Employer #4 Position Held Address (City, State, Zip) Phone (area code) Supervisor Name/Title Start Date End Date Major Responsibilities Reason for Leaving Ending Wage PROFESSIONAL LICENSES, REGISTRATIONS AND/OR CERTIFICATION Have you ever had a license, registration or certificate revoked or suspended? * If yes, please explain REFERENCES
List 3 individuals, not including relatives, who may be contacted for a professional reference.
MOTOR VEHICLE DRIVERS ABSTRACT
If the position for which I am applying requires, as a condition of employment, the possession of a valid driver’s license, I also authorize LCBDD to verify the validity of my driver’s license and/or review the state’s Motor Vehicle Registration Records.
Do you have a current Ohio Driver's License (Minimum Qualification) * Can you supply your own transportation to work? * Do you have auto liability insurance? (Minimum Qualification) * If yes, with whom? How many moving violations have you had in the past 3 years? * How many at-fault accidents have you had in the past 3 years? * NOTICE OF REQUIREMENT OF CRIMINAL BACKGROUND CHECK
I understand that the Lorain County Board of Developmental Disabilities (LCBDD)/Murray Ridge Center is required by Ohio law to conduct a record check of the criminal conviction history of an applicant under final consideration for employment. Ohio law and LCBDD policy make applicants with certain criminal conviction histories ineligible for employment. I understand that if requested I will be required to complete an affidavit regarding my criminal conviction history and be fingerprinted. The criminal conviction record check will be conducted by the Ohio Bureau of Criminal Investigation and Identification which agency may include information from the Federal Bureau of Investigation and, at LCBDD’s discretion, other state and/or federal agencies. The report of my criminal conviction history, if any, may be made available (pursuant to Ohio Revised Code Section 5123.081) to LCBDD Board members, LCBDD employees responsible for employment decisions or any hearing officer in the case of denial of employment. Upon request, I will be provided with a copy of the report. I understand and agree that my eligibility for employment is subject to and conditioned upon review and evaluation of the criminal conviction history, if any, contained in the report. I understand I must fully and completely disclose my criminal conviction history, if any, when requested.
I authorize LCBDD (its officers, agents, representatives or duly authorized employee) to make a thorough investigation of my past employment. I also agree to cooperate in such investigations and release from all liability or responsibility all persons, companies or corporations supplying such information. I grant permission for this application and attachments, if any, to be duplicated and distributed to LCBDD employees responsible for reviewing, interviewing and recommending applicants for employment and to LCBDD employees responsible for personnel records.
I understand and agree that an offer of employment is subject to and conditioned upon the results of a pre-employment physical, including a drug/alcohol screening and tuberculosis test or chest x-ray, verifying my fitness for duty and ability to perform the essential functions of the position with or without reasonable accommodation and I consent to the examinations and such future examinations as may be required by LCBDD.
I understand and agree, that as a condition of employment and continued employment, I shall meet and maintain any and all required standards for my position, including but not limited to certification, registration, licensure and/or training. I further understand and agree that in order to renew a certification, registration or licensure, or otherwise as a condition of continued employment, I may be required to enroll in and successfully complete college courses, classes, seminars and/or other job-related training which may be at my expense.
I hereby certify that the facts set forth in this employment application are true and complete to the best of my knowledge. I understand that if employed, any false or misleading statements on this application shall be considered sufficient cause for disqualification for employment or termination of my employment, at the discretion of LCBDD. By signing this agreement, I am acknowledging that I have thoroughly read the above and that its terms and conditions are fully understood.
Date Submitted * The Mission of Murray Ridge Center
Within existing resource constraints, to focus on a process of continuous quality improvement while collaborating with others in the community to expand opportunities for people with developmental disabilities.
The Board is an Equal Opportunity Employer
This philosophy calls for equal opportunity employment, training, and advancement regardless of sex, race, creed, color, age, national origin, religion, physical or mental disability or any other factors that are unrelated to the essential duties of the position.