Brighter Horizons Residential Services, Inc. - Employment Application Form

Education

Type Of School *

Name of School

Location (City & State)

Number of Years Completed

Major & Degree

High School

College

Business or Trade School

Professional School

Job Skills & Training
Use the space below to summarize additional information necessary to describe your full qualifications for the specific position for which you are applying. *
Training or Certifications (type N/A if not applicable):

Verification of Compliance with Employment Requirements and Authorization to Conduct Criminal Background Checks
As a condition of employment, I do verify that I have not been convicted or plead guilty to any of the offenses listed in the Rule 5123:2-2-02, including but not limited to, any of the offenses listed as Attachment A, attached and incorporated herein by reference, or of any other offense which bears a direct or substantial relationship to the duties or responsibilities of the position being filled. I am aware that should Brighter Horizons Residential Services, Inc. be informed through criminal background progress that I have been convicted of or pleaded guilty to any of these offenses listed in Rule 5123:2-2- or any of the offenses which bears a direct and substantial relationship to the duties and responsibilities of the position being filled, my employment shall be immediately terminated in accordance with the law.

I hearby authorize BHRS, Inc. access to requested criminal background information in accordance witht he Ohio Rule 5123:2-2-02. Such authorization shall remain in effect until receipt of the background investigation from the Bureau of Criminal Investigation and Identification, The Federal Bureau of Iinvestigation (if required), or any other applicable state or federal agency.

I also agree to inform the BHRS, Inc. office and my immediate supervisor if I am formerly charged with any offense listed in the Rule 5123:2-2-02, or any of the offenses which bears a direct and substantial relationship to the duties and responsibilities of the position being filled. This incident must be reported within 14 days of the charge, conviction, or guilty plea. Failure to report such charges may result in dismissal from employment
Signature: *

Clear
Name: *

First Name Last Name
Today's Date: *

Month Day Year
Date
Last four (4) digits of you Social Security Number: *
Attestation and Agreement to Notify Employer

I hereby attest that I have not been convicted of or pleaded guilty to any of the disqualifying offenses listed below and agree that I will notify Brighter Horizons Residential within 14 calendar days, if while employed I am formally charged with, am convicted of, or plead guilty to one of the disqualifying offenses. I understand that failure to make this notification may result in termination of employment.
Tier 1 Disqualifying Offenses (Permanent Exclusion):

2903.01 (aggravated murder)
2903.02 (murder)
2903.03 (voluntary manslaughter)
2903.11 (felonious assault)
2903.15 (permitting child abuse)
2903.16 (failing to provide for a functionally impaired person)
2903.34 (patient abuse and neglect)
2903.341 (patient endangerment)
2905.01 (kidnapping)
2905.02 (abduction)
2905.32 (human trafficking)
2905.33 (unlawful conduct with respect to documents)
2907.02 (rape)
2907.03 (sexual battery)
2907.04 (unlawful sexual conduct with a minor, formerly corruption of a minor)
2907.05 (gross sexual imposition)
2907.06 (sexual imposition)
2907.07 (importuning)
2907.08 (voyeurism)
2907.12 (felonious sexual penetration)
2907.31 (disseminating matter harmful to juveniles)
2907.32 (pandering obscenity)
2907.321 (pandering obscenity involving a minor)
2907.322 (pandering sexually oriented matter involving a minor)
2907.323 (illegal use of minor in nudity-oriented material or performance)
2909.22 (soliciting/providing support for act of terrorism)
2909.23 (making terrorist threat)
2909.24 (terrorism)
2913.40 (Medicaid fraud)
2923.01 (conspiracy) when the underlying offense is any of the offenses or violations on this list
2923.02 (attempt) when the underlying offense is any of the offenses or violations on this list
2923.03 (complicity) when the underlying offense is any of the offenses or violations on this list
A conviction related to fraud, theft, embezzlement, breach of fiduciary responsibility, or other financial misconduct involving a federal or state-funded program, excluding the disqualifying offenses set forth in section
2913.46 of the Revised Code (illegal use of supplemental nutrition assistance program [SNAP] or women, infants, and children [WIC] program benefits).
A violation of an existing or former municipal ordinance or law of this state, any other state, or the United States that is substantially equivalent to any of the offenses or violations on this list.

Tier 2 Disqualifying Offenses (Ten-Year Exclusion):

2903.04 (involuntary manslaughter)
2903.041 (reckless homicide)
2905.04 (child stealing) as it existed prior to July 1, 1996
2905.05 (criminal child enticement)
2905.11 (extortion)
2907.21 (compelling prostitution)
2907.22 (promoting prostitution)
2907.23 (enticement or solicitation to patronize a prostitute, procurement of a prostitute for another)
2909.02 (aggravated arson)
2909.03 (arson)
2911.01 (aggravated robbery)
2911.11 (aggravated burglary)
2913.46 (illegal use of supplemental nutrition assistance program [SNAP] or women, infants, and children [WIC] program benefits)
2913.48 (workers' compensation fraud)
2913.49 (identity fraud)
2917.02 (aggravated riot)
2923.01 (conspiracy) when the underlying offense is any of the offenses or violations on this list
2923.02 (attempt) when the underlying offense is any of the offenses or violations on this list
2923.03 (complicity) when the underlying offense is any of the offenses or violations on this list
2923.12 (carrying concealed weapon)
2923.122 (illegal conveyance or possession of deadly weapon or dangerous ordnance in a school safety zone, illegal possession of an object indistinguishable from a firearm in a school safety zone)
2923.123 (illegal conveyance, possession, or control of deadly weapon or dangerous ordnance into courthouse)
2923.13 (having weapons while under disability)
2923.161 (improperly discharging a firearm at or into a habitation or school)
2923.162 (discharge of firearm on or near prohibited premises)
2923.21 (improperly furnishing firearms to minor)
2923.32 (engaging in pattern of corrupt activity)
2923.42 (participating in criminal gang)
2925.02 (corrupting another with drugs)
2925.03 (trafficking in drugs)
2925.04 (illegal manufacture of drugs or cultivation of marihuana)
2925.041 (illegal assembly or possession of chemicals for the manufacture of drugs)
3716.11 (placing harmful objects in food or confection)
A violation of an existing or former municipal ordinance or law of this state, any other state, or the United States that is substantially equivalent to any of the offenses or violations on this list.

Tier 3 Disqualifying Offenses (Seven-Year Exclusion):

959.13 (cruelty to animals)
959.131 (prohibitions concerning companion animals)
2903.12 (aggravated assault)
2903.21 (aggravated menacing)
2903.211 (menacing by stalking)
2905.12 (coercion)
2909.04 (disrupting public services)
2911.02 (robbery)
2911.12 (burglary)
2913.47 (insurance fraud)
2917.01 (inciting to violence)
2917.03 (riot)
2917.31 (inducing panic)
2919.22 (endangering children)
2919.25 (domestic violence)
2921.03 (intimidation)
2921.11 (perjury)
2921.13 (falsification, falsification in theft offense, falsification to purchase firearm, or falsification to obtain a concealed handgun license)
2921.34 (escape)
2921.35 (aiding escape or resistance to lawful authority)
2921.36 (illegal conveyance of weapons, drugs, or other prohibited items onto grounds of detention
facility or institution)
2923.01 (conspiracy) when the underlying offense is any of the offenses or violations on this list
2923.02 (attempt) when the underlying offense is any of the offenses or violations on this list
2923.03 (complicity) when the underlying offense is any of the offenses or violations on this list
2925.05 (funding of drug or marihuana trafficking)
2925.06 (illegal administration or distribution of anabolic steroids)
2925.24 (tampering with drugs)
2927.12 (ethnic intimidation)
A violation of an existing or former municipal ordinance or law of this state, any other state, or the
United States that is substantially equivalent to any of the offenses or violations on this list.

Tier 4 Disqualifying Offenses (Five-Year Exclusion):

2903.13 (assault)
2903.22 (menacing)
2907.09 (public indecency)
2907.24 (soliciting after positive human immunodeficiency virus test)
2907.25 (prostitution)
2907.33 (deception to obtain matter harmful to juveniles)
2911.13 (breaking and entering)
2913.02 (theft)
2913.03 (unauthorized use of a vehicle)
2913.04 (unauthorized use of property, computer, cable, or telecommunication property)
2913.05 (telecommunications fraud)
2913.11 (passing bad checks)
2913.21 (misuse of credit cards)
2913.31 (forgery, forging identification cards)
2913.32 (criminal simulation)
2913.41 (defrauding a rental agency or hostelry)
2913.42 (tampering with records)
2913.43 (securing writings by deception)
2913.44 (personating an officer)
2913.441 (unlawful display of law enforcement emblem)
2913.45 (defrauding creditors)
2913.51 (receiving stolen property)
2919.12 (unlawful abortion)
2919.121 (unlawful abortion upon minor)
2919.123 (unlawful distribution of an abortion-inducing drug)
2919.23 (interference with custody)
2919.24 (contributing to unruliness or delinquency of child)
2921.12 (tampering with evidence)
2921.21 (compounding a crime)
2921.24 (disclosure of confidential information)
2921.32 (obstructing justice)
2921.321 (assaulting/harassing police dog or horse/service animal)
2921.51 (impersonation of peace officer)
2923.01 (conspiracy) when the underlying offense is any of the offenses or violations on this list
2923.02 (attempt) when the underlying offense is any of the offenses or violations on this list
2923.03 (complicity) when the underlying offense is any of the offenses or violations on this list
2925.09 (illegal administration, dispensing, distribution, manufacture, possession, selling, or using any
dangerous veterinary drug)
2925.11 (drug possession other than a minor drug possession offense)
2925.13 (permitting drug abuse)
2925.22 (deception to obtain dangerous drugs)
2925.23 (illegal processing of drug documents)
2925.36 (illegal dispensing of drug samples)
2925.55 (unlawful purchase of pseudoephedrine product)
2925.56 (unlawful sale of pseudoephedrine product)
A violation of an existing or former municipal ordinance or law of this state, any other state, or the
United States that is substantially equivalent to any of the offenses or violations on this list.
Signature: *

Clear
Name: *

First Name Last Name
Today's Date: *

Month Day Year
Date

Work Experience

Please list your work experience the past five years, beginning with your most recent employer. If you were self-employed, please indicate so. Attach resume or additional former employers.
Current Employer Name: *
Current Employer Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Current Employer Phone Number: *

Area Code Phone Number
Current Name of Supervisor: *

First Name Last Name
May We Contact Your Present Employer? *
Employment Date From: *

Month Day Year
Date
Employment Date To: *

Month Day Year
Date
Pay or Salary:
Reason For Leaving: *
List the jobs you held, duties performed, skills used or learned, advancements or promotions while your worked at this company: *

Employer #2 Name: *
Employer #2 Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Employer #2 Phone Number: *

Area Code Phone Number
Name of Supervisor: *

First Name Last Name
Employment Date From: *

Month Day Year
Date
Employment Date To: *

Month Day Year
Date
Pay or Salary:
Reason For Leaving: *
List the jobs you held, duties performed, skills used or learned, advancements or promotions while your worked at this company: *

Employer #3 Name: *
Employer #3 Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Employer #3 Phone Number: *

Area Code Phone Number
Name of Supervisor: *

First Name Last Name
Employment Date From: *

Month Day Year
Date
Employment Date To: *

Month Day Year
Date
Pay or Salary:
Reason For Leaving: *
List the jobs you held, duties performed, skills used or learned, advancements or promotions while your worked at this company: *
Did You complete this application yourself? *
If not, who did?

References

Please list two (2) references other that relatives, previous employers, or current employees of BHRS, Inc.
Reference 1
Name: *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number *

Area Code Phone Number

Reference 2
Name: *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number *

Area Code Phone Number

Application Form Waiver

In exchange for the consideration of my job application by Brighter Horizons Residential Services, Inc. (hereinafter called "BHRS, Inc.), I agree that: The facts set forth in my application are true and complete. I understand that, if employed, false statements on this application will be considered sufficient cause for dismissal.I hereby authorize BHRS, Inc. or it's agents to make an investigation of my employment and personal history though any investigative or credit agencies of its choice.I also understand that neither this application nor a commitment of employment by BHRS, Inc. constitutes a contract of employment. If a contract is to exist, that document will be executed in writing by BHRS, Inc. I understand that this application for employment is valid for no more than 60 days. After that, I must resubmit an application in order to be considered for positions at BHRS, Inc. Neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either in the position applied for or any other position, and regardless of the contents of employee handbooks, personnel manuals, benefit plans, policy statements, and the like as they may exist from time to time, or other BHRS, Inc. practices, shall serve to create an actual or implied contract of employment, or to confer any right to remain an employee of BHRS, Inc., or otherwise to change in any respect the employment at-will relationship between it and the undersigned, and that relationship cannot be altered except by a written instrument signed by the President/General Manager of BHRS, Inc.. Both the undersigned and BHRS, Inc. may end the employment relationship at any time, in accordance with BHRS, Inc. policy and procedures. If employed, I understand that BHRS, Inc. may unilaterally change or revise their benefits, policies and procedures and such changes may include reduction in benefits or pay.I authorize investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts called for is cause for dismissal at any time without any previous notice. I hereby give BHRS, Inc. permission to contact schools, previous employers (unless otherwise indicated), references, and others, and hereby release BHRS, Inc. from any liability as a result of such contract. I also understand that (1) BHRS, Inc. is required to obtain fingerprints and background information as required by local and federal authorities; (2) consent to and compliance with such policy is a condition of my employment; and (3) upon employment, I will notify BHRS, Inc. of any arrests or convictions that may subsequently occur within 14 days of such event. Failure to do so or falsification of background information may result in immediate termination of employment. I further understand that my employment with BHRS, Inc. shall be probationary for a period of ninety (90) days, and further that at any time during the probationary period or thereafter, my employment relation with BHRS, Inc. is terminable at will for any reason by either party.
Signature: *

Clear
** Please preview all of your answers before submitting your completed employment application. Answers cannot be changed once the "Submit Application" button has been clicked.
Today's Date: *

Month Day Year
Date
BHRS, Inc. is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, national origin, citizenship, age, or disability. We assure you that y our opportunity for employment with BHRS, Inc. depends solely on your qualifications
BHRS, Inc.
Brighter Horizons Residential Service, Inc.
1899 Hubbard Rd., Madison OH 44057
(440)-417-1751 or (866)-826-1806
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Brighter Horizons Residential Service, Inc. Employment Application

Education

Minimum Requirements

Physical Job Demands:

Verification of Compliance with Employment Requirements and Authorization to Conduct Criminal Background Checks

Attestation and Agreement to Notify Employer

Work Experience

Application Form Waiver