• Employment Application

    All fields marked with an asterisk * are required.
  • If you are unable to complete the application at one time, you will be able to save your progress by clicking the "Save" button at the bottom of each section. A link will be emailed to you for you to continue the application later.

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  • Job Descriptions are available here.

     

  • Education

  • Personal References

    Do not include relatives or former employers.
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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.
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  • Background Checks and Consents

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  • 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

  • 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.

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  • HR/Witness Signature ____________________________________________

  • Reference Request

    From Current or Previous Employers
  • 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.

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  • Reference Request

    From Current or Previous Employers
  • 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.

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  • 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, 

  • 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.

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  • Please answer the following questions:

  • 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.

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