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Application for Employment
Application for Employment
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APPLICANT INFORMATION
Applicant's Name (First Middile Initial Last)
*
Email Address
*
ApplicationDate (Today's date only)
Month
Month
May
Day
Day
29
Year
Year
2023
Street Address
*
Address Line 2 (if required)
City
*
State
*
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
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
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
ZIP
Prior Educational Institution Attended
Prior Institution Address (Street)
Grade Completed at Prior Institution
Degree or Certificate from Prior Institution
Prior Institution City
State
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
ZIP
Prior1 Educational Institution Attended
Prior Institution Address (Street)
Grade Completed at Prior Institution
Degree or Certificate from Prior Institution
Prior Institution City
State
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
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
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Year
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
Date To
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Year
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
Last Employer Phone
*
Supervisor's Name
Pay Rate
Reason for leaving
- None -
Resigned
Discharged
Other
Prior Employer1 - Company Name
Final Position Title
Date From
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Year
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
Date To
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Year
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
Prior Employer1 Phone
Supervisor's Name
Pay Rate
Reason for leaving
- None -
Resigned
Discharged
Other
Prior Employer2- Company Name
Final Position Title
Date From
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Year
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
Date To
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Year
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
Prior Employer2 Phone
Supervisor's Name
Pay Rate
Reason for leaving
- None -
Resigned
Discharged
Other
Prior Employer3 - Company Name
Final Position Title
Date From
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Year
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
Date To
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Year
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
Prior Employer3 Phone
Supervisor's Name
Pay Rate
Reason for leaving
- None -
Resigned
Discharged
Other
Position/Applicant Information
Recruitment Source
- None -
Akron Beacon Journal
College/University Referral
Canton Repository
Current Employee
Employee Referral
Flyers/Bookmarks
Former Employee
Good News paper
Job Fair
Kent Stater
Monster.com/Indeed etc.
Other
Record Courier
Walk In
Independence Web Site
Warren Tribune
Youngstown Vindicator
Hours/Days Available
*
For what position are you applying?
Preference
*
- Select -
Full Time
Part Time
Full or Part Time
Salary Requested?
Do you have a valid Driver's License
*
- Select -
Yes
No
License Number
*
State Licensed Issued by
*
- Select -
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
Do you have points on your License?
*
- Select -
Yes
No
How many points
*
Do you have reliable transportation to work?
*
- Select -
Yes
No
Have you lived in Ohio for the last 5 years?
*
- Select -
Yes
No
Choose other states of residency (Use and click if multiple states)
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
Have you ever been convicted of a crime other than a minor traffic violation?
*
- Select -
Yes
No
Explain the conviction
Have you ever filled out an application with Independence Inc. before?
*
- Select -
Yes
No
Give approximate Month and Year of prior application
Have any relatives of yours ever been employed by Independence Inc.?
*
- Select -
Yes
No
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