WOOD COUNTY ADAMH SERVICES BOARD APPLICATION FOR EMPLOYMENT

AN EQUAL OPPORTUNITY EMPLOYER

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PLEASE TYPE OR PRINT RESPONSES TO ALL OF THE QUESTIONS CONTAINED ON THE ENTIRE APPLICATION FORM

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POSITION SOUGHT: ________________________________________________________

LAST NAME: _______________________ FIRST NAME: ________________ MI: _____

HOME ADDRESS: ________________________ COUNTY: ________________________

CITY/STATE/ZIP: ________________________________________________________

HOME PHONE: ____________________________________________________________

SOCIAL SECURITY NUMBER: _______________________________________________

ARE YOU AN ADULT? YES:_____ NO: ______

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EMPLOYMENT HISTORY AND WORK EXPERIENCE

IN THIS SECTION, LIST ALL EMPLOYMENT HISTORY AND WORK EXPERINCE IN DATE ORDER, INCLUDING MILITARY EXPERIENCE. BEGIN WITH YOUR CURRENT EMPLOYER. USE ADDITIONAL PAPER IF NECESSARY. FAILURE TO INCLUDE ALL EMPLOYEMENT MAY BE GROUND FOR DISQUALIFICATION.

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CURRENT EMPLOYER: ____________________________________________________

(ENTER “NONE” IF UNEMPLOYED)

MAY WE CONTACT YOUR CURRENT EMPLOYER PRIOR TO EMPLOYMENT?

YES: ______ NO: _______

ADDRESS: _______________________________________________________________

PHONE NUMBER: ___________________________________________________________

DATES EMPLOYED: _______________________ TO _________________________

JOB TITLE: ________________________________________________________________

SUPERVISOR'S NAME:_________________________________________________________

BEGINNING SALARY: ___________ PER _____ ENDING SALARY: __________PER _____

DESCRIBE YOUR DUTIES, RESPONSIBILITIES, EQUIPMENT OPERATED, PROMOTIONS, ETC.: ________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

WHY DID YOU LEAVE? _____________________________________________________

________________________________________________________________________________

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PREVIOUS EMPLOYER: ____________________________________________________

ADDRESS: ________________________________________________________________________

PHONE NUMBER: ___________________________________________________________________

DATES EMPLOYED: _____________________ TO __________________________

JOB TITLE: ________________________________________________________________________

SUPERVISOR'S NAME:_________________________________________________________________

BEGINNING SALARY: ____________ PER _____ ENDING SALARY: ____________PER _____

DESCRIBE YOUR DUTIES, RESPONSIBILITIES, EQUIPMENT OPERATED, PROMOTIONS, ETC.: ___________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

WHY DID YOU LEAVE? _____________________________________________________

_________________________________________________________________________________

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PREVIOUS EMPLOYER: ______________________________________________________

ADDRESS: __________________________________________________________________

PHONE NUMBER: _______________________________________________________________

DATES EMPLOYED: _________________________ TO _____________________________

JOB TITLE: ________________________________________________________________________

SUPERVISOR'S NAME:_________________________________________________________

BEGINNING SALARY: ___________ PER _____ ENDING SALARY: ___________PER _____

DESCRIBE YOUR DUTIES, RESPONSIBILITIES, EQUIPMENT OPERATED, PROMOTIONS, ETC.: ______________________________________________________________________________

____________________________________________________________________________________

_____________________________________________________________________________________

WHY DID YOU LEAVE? ___________________________________________________________

______________________________________________________________________________________

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PREVIOUS EMPLOYER: ______________________________________________________

ADDRESS: ________________________________________________________________

PHONE NUMBER: ___________________________________________________________

DATES EMPLOYED: ____________________ TO __________________________

JOB TITLE: _______________________________________________________________

SUPERVISOR'S NAME:________________________________________________________

BEGINNING SALARY: __________ PER _____ ENDING SALARY: ___________PER _____

DESCRIBE YOUR DUTIES, RESPONSIBILITIES, EQUIPMENT OPERATED, PROMOTIONS, ETC.: ________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

WHY DID YOU LEAVE? ________________________________________________________

______________________________________________________________________________________

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PREVIOUS EMPLOYER: _________________________________________________________

ADDRESS: ___________________________________________________________________

PHONE NUMBER: ______________________________________________________________

DATES EMPLOYED: __________________________ TO _______________________________

JOB TITLE: __________________________________________________________________

SUPERVISOR'S NAME:__________________________________________________________

BEGINNING SALARY: __________ PER _____ ENDING SALARY: ____________PER _____

DESCRIBE YOUR DUTIES, RESPONSIBILITIES, EQUIPMENT OPERATED, PROMOTIONS, ETC.: ________________________________________________________________

__________________________________________________________________________

___________________________________________________________________________

WHY DID YOU LEAVE? _________________________________________________________

______________________________________________________________________________________

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IF YOU NEED TO LIST ANY ADDITIONAL PREVIOUS EMPLOYERS, PLEASE USE A BLANK SHEET OF PAPER TO DO SO.

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EDUCATION AND TRAINING

THIS SECTION IS INTENDED TO GIVE THE EMPLOYER INFORMATION ABOUT THE EDUCATION AND TRAINING THAT THE APPLICANT HAS COMPLETED, AND TO DEMONSTRATE THE SKILLS, KNOWLEDGE, AND ABILITIES OF THE APPLICANT TO PERFORM THE JOB DUTIES OF THE POSITION.

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HIGH SCHOOL ATTENDED: ____________________________________________________

ADDRESS: ________________________________________________________________

DID YOU GRADUATE? __________ HIGH SCHOOL EQUIVALENT? _____________________

COURSES PERTAINING TO JOB APPLIED FOR: ____________________________________

__________________________________________________________________________

ACTIVITIES, AWARDS, SPORTS, ETC.: ________________________________________

___________________________________________________________________________

___________________________________________________________________________

COLLEGE OR TRADE SCHOOL ATTENDED: __________________________________________

ADDRESS: __________________________________________________________________

DID YOU GRADUATE? _________ DEGREE: ______________________________________

COURSES PERTAINING TO JOB APPLIED FOR: ______________________________________

_____________________________________________________________________________

ACTIVITIES, AWARDS, SPORTS, ETC.: __________________________________________

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GRADUATE SCHOOL(S) ATTENDED: _________________________________________________

_______________________________________________________________________________

ADDRESS: _____________________________________________________________________

DID YOU GRADUATE? __________ DEGREE: ________________________________________

PLEASE USE THE FOLLOWING SPACE TO PROVIDE ANY FURTHER INFORMATION ON TRAINING, EDUCATION, SKILLS, ABILITIES, HOBBIES, VOLUNTEER WORK, ETC., THAT YOU POSSESS OR HAVE EXPERIENCED THAT MAY BE HELPFUL IN THE EVALUATION OF YOUR APPLICATION.

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PERSONAL INFORMATION

DO YOU HAVE ANY COMMITMENTS (I.E., SECOND JOB, SCHOOL, ETC.) WHICH MIGHT INTERFERE WITH, OR ADVERSELY AFFECT, YOUR EMPLOYMENT SHOULD WE SELECT YOU FOR A POSITION? YES: _____ NO: _____

IF YES, PLEASE EXPLAIN: _________________________________________________________

__________________________________________________________________________________

HAVE YOU EVER BEEN CONVICTED OF A FELONY? YES: _____ NO: _____

IF YES, PLEASE EXPLAIN: ___________________________________________________________

__________________________________________________________________________________

(THE EMPLOYER WILL ONLY CONSIDER SPECIFIC CRIMES RELATED TO QUALIFICATIONS FOR POSITIONS APPLIED FOR.)

DO YOU POSSESS A VALID DRIVERS LICENSE? YES: _____ NO: _____

IF NO, CAN YOU OBTAIN ONE PRIOR TO EMPLOYMENT? YES: _____ NO: _____

ARE YOU ELIGIBLE TO WORK IN THE UNITED STATES? YES: _____ NO: _____

ARE YOU A RESIDENT OF OHIO? YES: _____ NO: _____

IF NOT, ARE YOU WILLING TO BECOME A RESIDENT UPON EMPLOYMENT? YES: _____ NO: _____

PLEASE LIST THREE REFERENCES WHO ARE NOT RELATED TO YOU THAT YOU HAVE KNOWN AT LEAST ONE YEAR:

NAME: _____________________________________________________________________________

PHONE: ______________________ ADDRESS:____________________________________________

NAME: _____________________________________________________________________________

PHONE: ______________________ ADDRESS:____________________________________________

NAME: _____________________________________________________________________________

PHONE: ______________________ ADDRESS:____________________________________________

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PLEASE READ EACH OF THE FOLLOWING PARAGRAPHS CAREFULLY. INDICATE YOUR UNDERSTANDING OF, AND CONSENT TO, THE CONTENTS AND CONDITIONS OF EACH PARAGRAPH BY PLACING YOUR INITIALS AT THE END OF EACH PARAGRAPH. IF YOU HAVE ANY QUESTIONS REGARDING THESE PARAGRAPHS, CONTACT THE EMPLOYER BEFORE INITIALING THE PARAGRAPH.

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1. I understand and accept that, if I am selected for employment, my employment may be conditioned upon my passing any medical examination that the employer deems necessary to determine whether I can physically perform the essential functions of the position, with reasonable accommodation when necessary. I understand and accept that this may include drug, alcohol or substance abuse testing.

Initials: _____

2. If employed, I understand and accept that, depending on the department in which I am applying for employment, I may be required to work evening shifts or night shifts, including weekends and be on call and work mandatory overtime hours.

Initials: _____

3. I understand and accept that if any information required in this application is found to be falsified or intentionally excluded, my application may be disqualified from further consideration. I further understand and accept that if I am employed by the employer, I may be subject to disciplinary action, including termination, if any information required by this application has been falsified or intentionally excluded.

Initials: _____

4. I understand and accept that the employer requires a high degree of integrity and confidentiality of its employees. I also understand and accept that the various law enforcement and informational agencies that exchange information and data with the employer require that the employer's employees do not have a past record of unlawful activities. Therefore, I understand and accept that, depending on the department in which I am applying for employment, it may be necessary for the employer to investigate my background for any criminal or unlawful activity.

Initials: _____

5. I hereby authorize the employers, schools and personal references named in this application to provide information regarding me to the employer. I further authorize the release of personnel, academic and other records to the employer.

Initials: _____

I SOLEMNLY SWEAR THAT ALL OF THE INFORMATION FURNISHED IN THIS EMPLOYMENT APPLICATION IS TRUE, ACCURATE AND COMPLETE TO THE BEST OF MY KNOWLEDGE. I AUTHORIZE INVESTIGATION OF ALL STATEMENTS CONTAINED IN THIS APPLICATION. I UNDERSTAND THAT ANY MISREPRESENTATION OR FALSIFICATION OF THE INFORMATION PROVIDED MAY LEAD TO WITHDRAWAL OF AN EMPLOYMENT OFFER OR TERMINATION FOLLOWING EMPLOYMENT. I RECOGNIZE THAT MY FUTURE EMPLOYMENT WITH THE EMPLOYER WILL BE JEOPARDIZED IF I ENGAGE IN SUBSTANCE ABUSE, ILLEGAL DRUG USE, OR ALCOHOL ABUSE.

APPLICANT'S SIGNATURE __________________________________ DATE ____________________________________