APPLICATION FOR EMPLOYMENT

HALOM HOUSE INC (revised 1/2011)

 

 

 

PERSONAL INFORMATION:

 

Full LEGAL Name:    

Current Address:     

City:    State:     

Zip Code:    

Home Phone #:      Cell #:    

E-mail Address:    

 

If Married, Maiden Name:    

Place of Birth:      

 

Have you been a resident of Ohio for the previous three years?          YES         NO      

If NO, list city/state of residence for previous 5 years: 

  

POSITION APPLIED FOR:

 

Full-time:                          Part-Time:                        Substitute:    

 

Please indicate the HOURS of availability:

7am-3pm             3pm-12mid           12mid-7am             ALL hours     

 

Please indicate the DAYS of availability:

Monday – Friday                Saturday & Sunday                     ALL days    

 

 

Do you have commitments to another employer that may affect your employment with Halom House Inc.?  If so, please explainÉ

YES                       NO    

 

 

Can you furnish proof that you are 18 years or older? And eligible to work in the United States?

YES                       NO    

 

Have you been convicted of a felony and/or been imprisoned within the last 20 years?  If yes, explain.

YES                       NO    

 

 

Have you been charged with a crime that has not resulted in a plea of guilty, court trial, or charges dropped?  Explain.

YES                       NO    

 

 

Do you possess a valid Ohio driverÕs license?  If not an Ohio license, what state?

YES                       NO    

 

 

Do you own or lease a working vehicle?

YES                       NO    

 

Do you currently have valid Liability Auto Insurance?  With an offer of employment, a copy of insurance will have to be provided.

YES                       NO    

 

If the situation arose, would you be willing to take public transportation to and from work?

YES                       NO    

 

During the past 10 years have you been charged with a DUI? If yes, please indicate the dates (and state if NOT Ohio)É

YES                       NO    

 

 

Have you ever received psychological treatment? If so, please state the dates, diagnosis, and doctor.

YES                       NO    

 

 

Have you received training in CPR and/ 1st Aide?  Do you possess a valid certificate for CPR/1st Aide?

YES                       NO    

 

Have you received training in Medication Administration?  Do you possess a valid ÒDelegated NursesÓ certificate?

YES                       NO    

 

Have you worked in a direct care position with a person with Mental Retardation?

YES                       NO    

 

Have you received training in working with a person with disabilities? If yes, please explainÉ

YES                       NO    

 

 

Do you have physical limitations that would require special modifications to be made for you to perform the job you are applying for? If yes, please explainÉ

YES                       NO    

 

 

Please briefly describe why you want to work in this field (with people with disabilities).

 

Every agency has policies and procedures that employees are expected to follow.  Based on your personality and experience, what type of supervision do you need to ensure you are completing the job, which is expected of you?

 

 

WHAT WOULD YOU DO IN THIS SITUATION?

 

1.    You work in a home with 2 individuals, one becomes aggressive (verbally & physically) because they donÕt like what is on the menu for dinnerÉ

 

2.    You work in a home with 2 individuals needing 24/7 staff supervision, both individuals want to go out into the community but want to do different activitiesÉ

 

 

3.    You work in a home with 1 individual who consistently (and for no reason) wants to stay home from work during the weekÉ 

 

4.    You work with 2 individualsÉat med pass time you give client AÕs meds to client BÉ

 

 

5.    Every staff working at the site has certain housekeeping responsibilities to complete prior to end of shift, the person you relieve is NOT completing theirsÉ 

 

 

 

EDUCATION:

 

Elementary School:    

Address:    

Number of years completed:   Year of Grad:    

 

 

High School:    

Address:    

Number of years completed:   Year of Grad:   

Note: Upon offer of employment, you will need to provide proof of High School diploma or successful completion of GED program.

    

 

College:        

Address:    

Number of years attended:   Year of Grad:   

Major:    

Minor:     

 

 

Do you know American Sign Language?           YES                 NO    

Do you have a special skill or specialty?            YES                 NO    

If yes, please explain

 

 

Do you have any hobbies that are pertinent to position?        YES                 NO    

If yes, please explain

 

 

 

 

 

Character References:  (list at least one non-family member)

Name:                   Phone:    

Name:                   Phone:    

Name:                   Phone:    

 

 

PREVIOUS EMPLOYMENT (please list your past TWO employers from most recent to least recent.)

 

Company Name:   

 

Address/location:   

Company Phone Number:   

Company Fax Number:    

Company E-Mail:    

 

Name of Supervisor:   

 

Dates of Employment:    

 

Job Title:    

Salary or Rate of Pay:    

 

Describe Job Duties:    

 

Reason for Leaving:    

 

Are you eligible for re-hire with this company?   YES                NO    

If not, explain: 

 

Did you have attendance issues while employed?      YES                 NO    

If yes, please explain 

 

How would you rate your job performance with this company?

Excellent              Satisfactory          Poor    

 

 

 

 

 

 

 

Company Name:   

 

Address/location:   

Company Phone Number:   

Company Fax Number:    

Company E-Mail:    

 

Name of Supervisor:   

 

Dates of Employment:    

 

Job Title:    

Salary or Rate of Pay:    

 

Describe Job Duties:    

 

Reason for Leaving:    

 

Are you eligible for re-hire with this company?   YES                NO    

If not, explain: 

 

 

Did you have attendance issues while employed?      YES                 NO    

If yes, please explain 

 

How would you rate your job performance with this company?

Excellent              Satisfactory          Poor    

 

 

PLEASE READ CAREFULLY AND INITIAL EACH PARAGRAPH.

 

By my signature and initials placed below, I SWEAR that the information provided in this employment application (and accompanying resume if any) is true and complete.  I understand that any false information or significant omissions of facts may disqualify me from further consideration for employment and may be justification for my termination from employment if discovered at a later date.

Check if you agree:    

 

If hired, I agree to immediately notify my supervisor within fourteen calendar days if I should be formally charged, convicted of, or plead guilty of any crime  while employed with Halom House Inc.

Check if you agree:    

 

I give permission to Halom House Inc to request at any time a complete physical exam, which could include a drug screening and x-rays.  I consent to release to Halom House Inc all medical information as may be deemed necessary by Halom House Inc in judging my capabilities to do the work, which I am applying for and/or have been hired to do.

Check if you agree:    

 

I give permission to Halom House Inc to request at anytime a complete psychological exam and I consent to release to Halom House Inc all psychological information as may deemed necessary by Halom House Inc in judging my capability to do the work which I am applying and/or have been hired to do.

Check if you agree:    

 

I authorize the investigation of all statements contained in this application. I also authorize Halom House Inc to contact my present and past employers and listed references.  I understand that Halom House Inc may request and investigate consumer reports, workers comp claims, and any other information as to my character, reputation, personal characteristics, and mode of living.  I also understand that under the Federal Fair Credit Reporting Act, I have the right to make written request to Halom House Inc within a reasonable time for the disclosure of the name and address of the consumer reporting agency used to investigate so that you may obtain a complete disclosure of the nature and scope of the investigation.

Check if you agree:    

I authorize any persons, schools, current employers, organizations named in this application to provide Halom House Inc with any relevant and factual information and opinion that may be useful to Halom House Inc in making a hiring decision.  I release such persons etc from any legal liability in making such statements.

Check if you agree:    

 

I understand that this application does not, by itself, create a contract of employment.  I understand and agree that if hired, my employment with Halom House Inc is for no definite period of time and may, regardless of date of my wages/salary, be terminated at any time. I understand that no person is authorized to change any of the terms mentioned in this application except for the Executive Director and/or Halom House Inc Board of Director Designee.

Check if you agree:    

 

I understand that if hired, I will be placed in a position of responsibility for people with disabilities.  I will always keep their health and safety as my main concern during the time that I am supervising these individuals. I understand that I must arrive to work on time, for all shifts. To do otherwise, I would be jeopardizing the health and safety of the individuals I work with and risk termination of my employment with Halom House Inc.

Check if you agree:    

 

I hereby declare the information provided by me in this application for employment to be true, correct, and complete to the best of my knowledge.  I understand that if employed by Halom House Inc any mis-statement or omission of fact on this application shall be considered cause for termination.

 

 

_______________________________________________          _______________________________

ApplicantÕs Signature                                             Date

 

 

NOTE:  The Application must be signed with an original signature.