Employment Application

REFERENCES

Please list one professional reference and one personal reference.
Professional Reference
Name*

First NameLast Name
Relationship*
Company Name*
Years Known*
Phone Number

Area CodePhone Number
Personal Reference
Name*

First NameLast Name
Relationship*
Years Known*
Phone Number*

Area CodePhone Number

EDUCATION AND TRAINING
High School
Name of School*
Location*
Did you graduate?*

YesNo
If no, how many years completed?
Honors/Degree/Specialized Course of Study?
College
Name of College
Location
Did you graduate?

YesNo
If no, how many years completed?
Honors/Degree/Specialized Course of Study?
Trade/Business/Technical/Other
Name of School
Location
Did you graduate?

YesNo
If no, how many years completed?
Honors/Degree/Specialized Course of Study?

EMPLOYMENT

Do not substitute a resume for this section
Company #1

In accordance with Ohio Administrative Code 5123:2-2-02, section C, paragraph 1b, FCDS will attempt to obtain a reference from this employer.
Company Name*
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Job Title*
Supervisor Name*

First NameLast Name
HR or Supervisor Email Address:*
example@example.com
Responsibilities*
Reason for Leaving*
Dates Employed: From*
Dates Employed: To*
Starting Pay*
Ending Pay*
Company #2

In accordance with Ohio Administrative Code 5123:2-2-02, section C, paragraph 1b, FCDS will attempt to obtain a reference from this employer.
Company Name*
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Job Title*
Supervisor Name*

First NameLast Name
HR or Supervisor Email Address:*
example@example.com
Responsibilities*
Reason for Leaving*
Dates Employed: From*
Dates Employed: To*
Starting Pay*
Ending Pay*
Company #3

In accordance with Ohio Administrative Code 5123:2-2-02, section C, paragraph 1b, FCDS will attempt to obtain a reference from this employer.
Company Name
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Job Title
Supervisor Name

First NameLast Name
HR or Supervisor Email Address:
example@example.com
Responsibilities
Reason for Leaving
Dates Employed: From
Dates Employed: To
Starting Pay
Ending Pay

SKILLS
Please use this space to list any special skills, volunteer experiences, etc. that may relate to the position for which you are applying.

BACKGROUND INVESTIGATION AUTHORIZATION DISCLOSURE

In accordance with Ohio Administrative Code 5123:2-2-02, the following criteria will be required.
Applicant must provide/obtain the following:
- Proof of HS Diploma, GED, or College Degree
- BCII Background Check
- FBI Background Check
- Proof of Vehicle Insurance
- Current Driver's License
- Proof of First Aid and CPR Certification
- Social Security Card
- Birth Certificate
FCDS will complete background checks to include, but not limited to, the following:
- Abuser Registry
- Sex Offender Database
- United States General Services Administration System (Inspector General & SAM)
- Database of Incarcerated and Supervised Offenders
- Nurse Aide Registry
- Controlled Substance Testing
- Ohio BMV
- Physical Exam
If your name appears negatively on any of the above checks, FCDS is prohibited to hire/employ you.

Therefore, we will not consider for hire, nor continue to employ an applicant or employee that appears on any of the above databases.

All checks are done on a regular basis.

FCDS will not share any information obtained by these checks to any outside entity without your prior consent.

By signing this application, you acknowledge that you have read this section and understand it.

PROOF OF RESIDENCY
Proof of Residency*

I have lived in the state of Ohio for at least 5 years prior to today.I have not lived in the state of Ohio for at least 5 years prior to today.
Proof of Residency Signature*

Clear

DISQUALIFYING OFFENSES

There are five tiers of disqualifying offenses with corresponding time periods that prevent an applicant from being considered for employment or a current employee from remaining employed at FCDS.
TIER 1

FCDS cannot hire an applicant or continue to employ an employee if they have been convicted of or plead guilty to any of the following:
- aggravated murder
- murder
- voluntary manslaughter
- felonious assault
- permitting child abuse
- failing to provide for a functionally impaired person
- patient abuse and neglect
- patient endangerment
- kidnapping
- abduction
- human trafficking
- unlawful conduct with respect to documents
- rape
- sexual battery
- unlawful sexual conduct with a minor, formerly corruption of a minor
- gross sexual imposition
- sexual imposition
- importuning
- voyeurism
- felonious sexual penetration
- disseminating matter harmful to juveniles
- pandering obscenity
- pandering obscenity involving a minor
- pandering sexually oriented matter involving a minor
- illegal use of minor in nudity-oriented material or performance
- soliciting/providing support for act of terrorism
- making terrorist threat
- terrorism
- Medicaid fraud
- conspiracy, attempt, 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 responsiblity, 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 or women, infants, and children 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 described on this list.
TIER 2

FCDS cannot hire an applicant or continue to employ an employee for a period of ten years from the date the applicant/employee was fully discharged from imprisonment, probation, and parole if the applicant/employee has been convicted of or pleaded guilty to any of the following:
- involuntary manslaughter
- reckless homicide
- child stealing (as existed prior to 7/1/1996)
- criminal child enticement
- extortion
- compelling prostitution
- promoting prostitution
- enticement or solicitation to patronize a prostitute, procurement of a prostitute for another
- aggravated arson
- arson
- aggravated robbery
- aggravated burglary
- illegal use of supplemental nutrition assistance program or women, infants, and children program benefits
- workers' compensation fraud
- identity fraud
- aggravated riot
- carrying concealed weapon
- illegal conveyance or possession of deadly weapon or dangerous ordinance in a school safety zone, illegal possession of an object indistinguishable from a firearm in a school safety zone)
- illegal conveyance, possession, or control of deadly weapon or dangerous ordinance into courthouse
- having weapons while under disability
- improperly discharging a firearm at or into a habitation or school
- discharge of firearm on or near prohibited premises
- improperly furnishing firearms to minor
- engaging in pattern of corrupt activity
- participating in criminal gang
- corrupting another with drugs
- trafficking in drugs
- illegal manufacture of drugs or cultivation of marijuana
- illegal assembly or possession of chemicals for the manufacture of drugs
- placing harmful objects in food or confection
- conspiracy, attempt, complicity when the underlying offense is any of the offenses or violations on this list
- 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 described on this list.
TIER 3

FCDS cannot hire an applicant or continue to employ an employee for a period of seven years from the date the applicant/employee was fully discharged from imprisonment, probation, and parole if the applicant/employee has been convicted of or pleaded guilty to any of the following:
- cruelty to animals
- prohibitions concerning companion animals
- aggravated assault
- aggravated menacing
- menacing by stalking
- coercion
- disrupting public services
- robbery
- burglary
- insurance fraud
- inciting to violence
- riot
- inducing panic
- endangering children
- domestic violence
- intimidation
- perjury
- falsification, falsification in theft offense, falsification to purchase firearm, or falsification to obtain a concealed handgun license
- escape
- aiding escape or resistance to lawful authority
- illegal conveyance of weapons, drugs or other prohibited items onto grounds of detention facility or institution
- funding of drug or marijuana trafficking
- illegal administration or distribution of anabolic steroids
- tampering with drugs
- ethnic intimidation
- conspiracy, attempt, complicity when the underlying offense is any of the offenses or violations on this list
- 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 described on this list.
TIER 4

FCDS cannot hire an applicant or continue to employ an employee for a period of five years from the date the applicant/employee was fully discharged from imprisonment, probation, and parole if the applicant/employee has been convicted of or pleaded guilty to any of the following:
- assault
- menacing
- public indecency
- soliciting after positive human immunodeficiency virus test
- prostitution
- deception to obtain matter harmful to juveniles
- breaking and entering
- theft
- unauthorized use of a vehicle
- unauthorized use of property, computer, cable, or telecommunication property
- telecommunications fraud
- passing bad checks
- misues of credit cards
- forgery, forging indentification cards
- criminal simulation
- defrauding a rental agency or hostelry
- tampering with records
- securing writings by deception
- personating an officer
- unlawful display of law enforcement emblem
- defrauding creditors
- receiving stolen property
- unlawful abortion
- unlawful abortion upon minor
- unlawful distribution of an abortion-inducing drug
- interference with custody
- contributing to unruliness or delinquency of child
- tampering with evidence
- compounding a crime
- disclosure of confidential information
- obstructing justice
- assaulting/harassing police dog or horse/service animal
- impersonation of peace officer
- illegal administration, dispension, distribution, manufacture, possession, selling, or using any dangerous veterinary drug
- drug possession other than a minor drug possession offense
- permitting drug use
- deception to obtain dangerous drugs
- illegal processing of drug documents
- illegal dispensing of drug samples
- unlawful purchase of pseudoephedrine product
- unlawful purchase of pseudoephedrine product
- unlawful sale of pseudoephedrine product
- conspiracy, attempt, complicity when the underlying offense is any of the offenses or violations on this list
- 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 described on this list.
TIER 5

FCDS may employ an applicant or continue to employ an employee, no exclusion, if applicant/employee has been convicted of or pleaded guilty to any of the following:
- drug possession that is minor drug possession offense
- illegal use or possession of drug paraphernalia
- illegal use or possession of marijuana drug paraphernalia
- 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 described on this list.
*Multiple offenses, according to the Rule, may result in different exclusionary periods than what is listed above.

I hereby attest that I have not: 1) been convicted of, 2) pleaded guilty to, or 3) been found eligible for intervention in lieu of conviction, for any of the disqualifying offenses listed above and agree that I will notify my employer, First Christian Church, within 14 calendar days, if while employed, I am formally charged with, am convicted of, plead guilty to, or am found eligible for intervention in lieu of conviction for any of the disqualifying offenses. I understand that failure to make this notification may result in termination of employment.
(signature below)
Disqualifying Offense Signature*

Clear
I will notify First Christian Day Services Director within 14 days if I am ever charged with, plead guilty to, or am convicted of any of the disqualifying offenses listed above.
(signature below)
14 Day Notification Signature*

Clear

RANDOM CONTROLLED SUBSTANCE TEST

In addition to the required controlled substance test upon hire, FCDS may require an employee to complete random controlled substance testing.
I agree to provide a urine and/or hair sample or breathalyzer for the purpose of drug or alcohol testing and analysis if requested by FCDS. I also grant permission to have the results of such testing released to my employer.
(signature below)
Random Controlled Substance Test Signature*

Clear
Note: If employee is involved in an accident while driving a company vehicle and it involves any of the following circumstances, a controlled substance test must be completed within 32 hours and complete testing for blood alcohol level within 8 hours of the accident.

The driver cited under state or local law for a moving traffic violation arising from the accident, if the accident involved:
- Bodily injury to any person who, as a result of the injury, immediately receives medical treatment away from the scene of the accident, or
- One or more motor vehicles incurred disabling damage as a result of the accident, requiring the motor vehicle to be transported away from the scene by a tow truck or other motor vehicle.
- The accident involves loss of human life.

AGREEMENT
I, the undersigned applicant, hereby certify that the information contained on this Employment Application is true and correct, and I have not omitted any facts which I reasonably believe would reflect unfavorably on FCDS’s decision to hire me. By signing below I authorize FCDS to contact any person or institution I have listed on this application. In addition, I hereby authorize FCDS to verify any information I have provided and I further authorize any of the named schools, companies, or persons listed to provide any information about me contained in their records and release them from liability for such disclosure. My signature below hereby authorizes disclosure of information and releases FCDS, its offices and employees from liability for such disclosures. I understand that employment with FCDS is for no definite period and may be terminated by either the employee or the employer, at any time, with or without notice, and with or without cause. I understand that First Christian Church has statutory and constitutional privileges which make it exempt from the prohibition against religious discrimination in the selection process. If this application leads to employment, I understand that false or misleading information in my application or interview may result in termination. I understand that FCC does not participate in the State of Federal Unemployment Trust Fund. I fully understand that I will not be able to receive unemployment benefits as a result of my work here. Should I choose to not work past my 90-day orientation period, I agree to pay back any expenses FCDS incurred to secure my employment.
(signature below)
Agreement Signature*

Clear
Should be Empty:

Employment Application

REFERENCES

Professional Reference

Personal Reference

EDUCATION AND TRAINING

High School

College

Trade/Business/Technical/Other

EMPLOYMENT

Company #1

Company #2

Company #3

CHRISTIAN BACKGROUND

SKILLS

BACKGROUND INVESTIGATION AUTHORIZATION DISCLOSURE

PROOF OF RESIDENCY

DISQUALIFYING OFFENSES

TIER 1

TIER 2

TIER 3

TIER 4

TIER 5

RANDOM CONTROLLED SUBSTANCE TEST

AGREEMENT