Application for Employment

1 Start 2 EndOnlineForm 3 EndFinalzed 4 Complete

Page 1 of 4

APPLICANT INFORMATION

Applicant's Name (First Middile Initial Last) *

Email Address *

ApplicationDate (Today's date only)

Month

Day

Year

Street Address *

Address Line 2 (if required)

City *

State *

ZIP Code *

Phone

EMERGENCY CONTACT INFORMATION

IN CASE OF EMERGENCY NOTIFY:

Relationship (i.e. Spouse/Mother etc.)

Contact's Work Phone

A work or home number is required

Contact's Address

Contact's Home Phone

EDUCATION

Name of Last Educational Institution Attended

Last Institution Address (Street)

Grade Completed at Last Institution

Degree or Certificate from Last Institution

Last Institution City

State

ZIP

Prior Educational Institution Attended

Prior Institution Address (Street)

Grade Completed at Prior Institution

Degree or Certificate from Prior Institution

Prior Institution City

State

ZIP

Prior1 Educational Institution Attended

Prior Institution Address (Street)

Grade Completed at Prior Institution

Degree or Certificate from Prior Institution

Prior Institution City

State

ZIP

Other Training Related to Employment:

EMPLOYMENT HISTORY - In order from the LATEST to the OLDEST

Last Employer - Company Name

Final Position Title

Date From

Month

Day

Year

Date To

Month

Day

Year

Last Employer Phone *

Supervisor's Name

Pay Rate

Reason for leaving

Prior Employer1 - Company Name

Final Position Title

Date From

Month

Day

Year

Date To

Month

Day

Year

Prior Employer1 Phone

Supervisor's Name

Pay Rate

Reason for leaving

Prior Employer2- Company Name

Final Position Title

Date From

Month

Day

Year

Date To

Month

Day

Year

Prior Employer2 Phone

Supervisor's Name

Pay Rate

Reason for leaving

Prior Employer3 - Company Name

Final Position Title

Date From

Month

Day

Year

Date To

Month

Day

Year

Prior Employer3 Phone

Supervisor's Name

Pay Rate

Reason for leaving

Position/Applicant Information

Recruitment Source

Hours/Days Available *

For what position are you applying?

Preference *

Salary Requested?

Do you have a valid Driver's License *

License Number *

State Licensed Issued by *

Do you have points on your License? *

How many points *

Do you have reliable transportation to work? *

Have you lived in Ohio for the last 5 years? *

Choose other states of residency (Use and click if multiple states)

Have you ever been convicted of a crime other than a minor traffic violation? *

Explain the conviction

Have you ever filled out an application with Independence Inc. before? *

Give approximate Month and Year of prior application

Have any relatives of yours ever been employed by Independence Inc.? *

List relative's names:

REFERENCES - Two Professional One Personal (Relatives are not acceptable references)

Ref1Name *

Ref1Relationship *

Ref1Phone *

Ref2Name *

Ref2Relationship *

Ref2Phone *

Ref3Name *

Ref3Relationship *

Ref3Phone *

1. What additional information should we consider that you think makes you an ideal candidate to work with adults with developmental disabilities?

2. What are your long term career or life goals?

INDEPENDENCE, INC. selects the most qualified individuals for the job, based upon job-related qualifications, regardless of race, color, creed, sex, national origin, age handicap, or other protected groups under state, federal, or local Equal Opportunity Laws.

I understand and Agree That:

1. Any material misrepresentations, or deliberate omission of a fact in my application may be justification for refusal of or, if employed, termination from employment.

2. It is my understanding that INDEPENDENCE, INC. will make a thorough investigation of my entire work history and may verify all data given in my application for employment, drug test/screen, related papers, or oral interviews. I authorize such investigation and the giving and receiving of any information requested by INDEPENDENCE, INC. and I release from liability any person giving or receiving any such information. I understand that falsification of data so given or other derogatory information discovered as a result of this investigation may prevent my being hired, or if hired, may subject me to immediate dismissal.

3. It is my understanding that I am expected to keep Human Resources informed in writing of any changes in my status within three (3) working days of the change. This includes notification of any change in Motor Vehicle license status (including any citations issued) and criminal records status (including arrests).

I further understand that this is an application for employment and that no employment contract is being offered. I understand that if I am employed, such employment is for no definite period of time and that INDEPENDENCE, INC. can change wages, benefits, and conditions at any time. I have read and understand the above and certify that the information I have provided on this application is accurate to the best of my knowledge. *

Name and Date

Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Marianas Islands
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming