Application for Siffrin

Personal References

Do not include relatives or former employers.
Name *

First Name Last Name
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Address *

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Phone Number *

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Name *

First Name Last Name
Occupation *
Address *

Street Address

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Phone Number *

Area Code Phone Number
Name *

First Name Last Name
Occupation *
Address *

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Employment History

Start with your present or most recent job. Include any job-related military service assignments and volunteer activities. References are checked, so please provide complete information for all companies listed. If you have no previous employment, enter N/A in the first "Company" field.
Company *
Job Title *
Supervisor *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
Starting Wage *
Ending Wage *
Dates Employed *
Status *

Full Time Part Time
Reasons for Leaving *
Job Duties *
Company
Job Title
Supervisor
Address

Street Address

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Starting Wage
Ending Wage
Dates Employed
Status

Full Time Part Time
Reasons for Leaving
Job Duties
Company
Job Title
Supervisor
Address

Street Address

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Phone Number

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Starting Wage
Ending Wage
Dates Employed
Status

Full Time Part Time
Reasons for Leaving
Job Duties

Background Checks and Consents
Interview Location *
Name *

First Name Last Name
Date *

Month Day Year
As part of the application and hiring process, we are required by laws to complete a criminal background check for you. This is not done because we do not trust you. This is done to protect the individuals we serve and our staff members.

Please read over the attached list of disqualifying offenses as described in Ohio Rule 5123:2-2-02, Background Investigations for Employment. If you have pleaded guilty or have been convicted of any of the offenses listed, you may not be eligible for employment with Siffrin.

Additionally, any offenses that may appear on your record that would be in conflict with the requirements of the position, or agency policy, would prohibit your employment with Siffrin. Please ask if you have any questions.

Thank you,

The Human Resources Department
Have you ever been convicted of any of the offenses listed in this application addendum, including any existing or former municipal ordinance or law of this state, or any other state, or the United States that is substantially equivalent to the offenses. *

Yes No
If Yes, please list all information regarding the conviction.
By signing this form, I consent to the submission of a request for a criminal record check for direct care workers as required by Ohio Rule 5123:2-2-02, Background Investigations for Employment. Siffrin will submit the request to BCI in London, Ohio. The check will include a search of Ohio records and may or may not include an FBI check of the United States.

I attest to the following:

I have not been convicted or plead guilty to any of the offenses that would disqualify me from working with ID/DD individuals under Ohio Rule 5123:2-2-02, Background Investigations for Employment. I have viewed a list of disqualifying offenses. I do not have any offenses on my record that would be in conflict with the requirements of the position or agency policy based upon the job description that I have reviewed. I have had the opportunity to ask any questions that I may have about any specific charges.

I understand and agree that if I am found to have a record of any of those offenses, I will not be hired for work with ID/DD individuals or, if I have already been hired, my employment will be terminated.

I understand that if I am employed by the agency, I am responsible to report to them within 14 calendar days any change to the status of my background check. This would include my being charged with an offense, being convicted of an offense, or by pleading guilty to an offense that is on Ohio Rule 5123:2-2-02, Background Investigations for Employment, or in conflict with the agency’s policy or the requirements of the position.

I further understand that my failure to do so may result in my immediate termination from the agency.

I was informed that I must provide fingerprint impressions and that a criminal record check must be conducted if I come under final consideration for employment.
I understand that the following checks are required before my employment with Siffrin, Inc. I understand that if I have any violations come back on these potential checks below I am not eligible for hire with Siffrin, Inc.

-          Nurse’s Aide Registry

-          Abuser Registry

-          Driver’s License Check

-          List of Excluded Person’s

-          Sex and Child Offender’s

-          United States General Services

-          Incarcerated and Supervised Offenders

I understand that if employed by the agency I am responsible to report to them within 14 calendar days any change to the status of these required checks.

I further understand that my failure to do so may result in my immediate termination from the agency.

Motor Vehicle Check

As part of the application and hiring process, we are required to complete a driving record check for you. This is done in compliance with the agency’s automobile insurance policy requirements.

Please read over the attached list if violations carefully.

In the past three years, if you have one or more of the Type A violations, you are not eligible for employment with the agency.

Also, if you have three or more Type B violations in the past three years, you are also not eligible for employment.

The agency guidelines also state that you may not have more than 4 points and/or two convictions within that past three years for drivers, two years for any other staff.

Please ask if you have any questions.

Thank you,

Tara MacLean, Director of Human Resources

Type A Violations

DWI/DUI/DWUI-Drugs or Alcohol

Refusing to take a substance test

Driving with an open container

Negligent homicide using a motor vehicle

Driving while license is suspended or revoked

Operating a motor vehicle for the commission of a felony

Aggravated assault with a motor vehicle

Permitting an unlicensed person to drive

Reckless driving

Fleeing or evading police or roadblock

Resisting arrest

Speed contest (racing)

Hit and run

Failure to report an accident

Illegal passing of a school bus

Other violations considered serious by state law

Type B Violations

Speeding

Improper lane change

Failure to yield

Failure to obey a traffic signal or sign

Careless driving

Accidents

By signing this form, I consent to the submission of a request for a motor vehicle report. I understand that I am entitled to a copy of my report and that I must only request this through the HR Department should I desire it.

I attest to the following:

            I have reviewed a list of Type A and Type B violations that may or may not be included on my motor vehicle report.

            I have had the opportunity to ask any questions that I may have about any specific violations.

            I understand and agree that I must meet the agency’s insurance policy requirement with respect to my driving record in order to be considered for any position that would require me to drive.

            I understand that if employed by the agency I am responsible to report to them within 14 calendar days any change to the status of my motor vehicle report.

            I further understand that my failure to do so may result in my immediate termination from the agency.

Substance Screening Consent and Release

As an employee/applicant of Siffrin, Inc. I hereby acknowledge the agency policy, which requires me to submit to urine testing and/or breath alcohol testing.

I further understand that the purpose of this analysis is to determine or rule out the presence of non-prescribed or prohibited dangerous controlled substances in my system,

I hereby freely and voluntarily consent to this request for a urine sample and/or breath alcohol test and agree to participate in the testing program.

I hereby and herewith release Siffrin, its employees, agents, and contractors from any and all liability whatsoever arising from this request for testing, from the actual testing procedures, and from decisions made concerning my application for or consideration of employment based on the results if the analysis.

I agree to cooperate in all aspects of the testing procedure.

I agree that my signature on this form is my authorization to have the cost of the drug screening deducted from my paycheck in the event the results are positive, and I am ineligible for employment with Siffrin, Inc.

I hereby authorize the release of my drug and/or alcohol test results to the contractor’s Medical Review Officer (MRO).

I further acknowledge that the agency has provided me with an opportunity to ask questions related to its drug and alcohol testing program and that all my questions have been answered.
Signature *

Clear
Date *

Month Day Year
HR/Witness Signature ____________________________________________

Reference Request

From Current or Previous Employers
Name *

First Name Last Name
Select one of the following options: *
Company 1 *
Did this employment involve a CMV or a CDL? *

Yes No
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
I, the undersigned, have made application with Siffrin, Inc. I hereby authorize any related investigation of my past, whether or not it is of record. I release all persons assisting in such investigation from any liability related to the disclosure of such information.
Signature *

Clear
Date *

Month Day Year

Reference Request

From Current or Previous Employers
Name *

First Name Last Name
Company 2 *
Did this employment involve a CMV or a CDL? *

Yes No
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
I, the undersigned, have made application with Siffrin, Inc. I hereby authorize any related investigation of my past, whether or not it is of record. I release all persons assisting in such investigation from any liability related to the disclosure of such information.
Signature *

Clear
Date *

Month Day Year

Attestation and Agreement to Notify Employer
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 below and agree that I will notify my employer,
Employer Name
Siffrin, Inc.
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.
Name *

First Name Last Name
Signature *

Clear
Date *

Month Day Year
Date

Please answer the following questions:
1. If a doctor gives you 3 pills with instructions to take one every half hour starting at 1:00, at what time will you take the last pill? *
2. Do they have 4th of July in England? *
3. Some months have 30 days, some 31. How many have 28 days? *
4. A plane crashes on the border of Canada and the USA. 60 die. Where do they bury the survivors? *
5. I have 10 apples, and I give all but 6 away. How many do I have left? *
6. If someone takes one pill twice daily, how many pills will they need for 1 week? *
7. How many times can you take 5 out of 25? *
8. Jack left school at 3:30 pm and got home at 4:45 pm. How many minutes did the trip take him? *
9. How many months are there in one decade? *
10. Start with 100, add 10, add 100, add 20, add 100, add 30, add 100 and add 40. What is the total? *
Applicant's Statement
Siffrin Inc. selects the best-matched individual for the job based upon job-related qualifications, regardless of race, creed, sex, national origin, age, handicap or other protected groups under federal, state, or local Equal Opportunity Laws.

A satisfactory two-step tuberculin test, criminal background check, driving record report, and urine drug screen will be required PRIOR to employment. I certify that answers given herein are true and complete to the best of my knowledge.

I give permission/authorization for an investigation of all statements contained in this application for employment necessary in arriving at an employment decision. This includes providing a set of fingerprint impressions for the required criminal history check.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an "at will" nature, which means that the employee may resign at any time and the employer may discharge the employee at any time with or without cause. It is further understood that this at-will employment relationship may not be changed by any written document or by conduct unless an executive of this organization specifically acknowledges such change in writing.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.
Date *
Date *
Your Signature *

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