ACBDD EMPLOYMENT APPLICATION

EMPLOYMENT APPLICATION
TO ALL APPLICANTS - (Please read carefully) Thank you for your interest in employment with the Athens County Board of Developmental Disabilities (ACBDD). The ACBDD provides a broad range of supportive services to children and adults with developmental disabilities who live in Athens County. You may submit a resume with your application, but we require that all of the information asked for on this application be completed also.

Please provide as much detail as possible and answer all questions thoroughly. If you need assistance completing the application, please advise the Human Resources (HR) representative. You may follow up with your application by contacting: personnel@athenscbdd.org.

Please NOTE:
- On Page 2 of the application, there are spaces provided for positions for which you are applying. If you wish to apply for more than two, please make a notation in box 2.
- There is a Voluntary Demographic Data form that will be offered after completion. We advise you that: (a) applicants are under no obligation to respond but may do so if they choose; (b) responses will remain confidential within the human resource department, and (c) responses will be used only for the necessary information to include in our affirmative action program.
Our office hours are Monday through Friday, 8:00 a.m. until 4:00 p.m.
HIRING PROCESS
Completed applications are received and reviewed by the HR representative and made available to the supervisors in the facilities where appropriate openings exist based upon the applicant’s stated areas of interest and qualifications.

All offers of employment are contingent upon successful completion of a job-related medical examination, a criminal history background check, and, if the position requires the person to transport clients or operate agency vehicles for any other purpose, a driving abstract.

PERSONAL INFORMATION
First Name*
Middle Name
Last Name*
Street Address*
City*
State*
Zip*
Telephone number*
E-mail address
example@example.com
Position(s) applied for 1
Rate of pay expected $ per
Position(s) applied for 2
Rate of pay expected $ per
How did you learn of this opening?
Do you have friends or relatives working for this agency? (It is ACBDD policy not to place an employee under the supervision of a friend or relative)

YesNo
Can you perform the essential functions of the specific jobs for which you are applying as listed in the Position Description?

YesNo
If NO, please list which essential functions you would have difficulty performing and identify possible reasonable accommodations

EMPLOYMENT HISTORY - List most recent first. If your job title or duties changed during employment with any one employer, please list as separate employers.
Name of Employer
Telephone
Address

Address

Street Address Line 2

CityState

Zip
Name & Title of Supervisor
Job Title
Dates of Employment

MonthDayYear
Start Date
End Date

MonthDayYear
Date
Ending Salary
Describe Responsibilities
Reason for Leaving
May we contact this employer for reference check?

YesNo
Name of Employer 2
Telephone
Address

Address

Street Address Line 2

CityState

Zip
Name & Title of Supervisor
Job Title
Dates of Employment

MonthDayYear
Start Date
End Date

MonthDayYear
End Date
Ending Salary
Describe Responsibilities
Reason for Leaving
May we contact this employer for reference check?

YesNo
Name of Employer 3
Telephone
Address

Address

Street Address Line 2

CityState

Zip
Name & Title of Supervisor
Job Title
Dates of Employment

MonthDayYear
Start Date
End Date

MonthDayYear
End Date
Ending Salary
Describe Responsibilities
Reason for Leaving
May we contact this employer for reference check?

YesNo

References

List three references, EXCLUDING RELATIVES, whom this agency has permission to contact.
1. Name
1. Relationship to you
1. Occupation
1. Home Address or Email Address
1. Phone Number
Please enter a valid phone number.
2. Name
2. Relationship to you
2. Occupation
2. Home Address or Email Address
2. Phone Number
Please enter a valid phone number.
3. Name
3. Relationship to you
3. Occupation
3. Home Address or Email Address
3. Phone Number
Please enter a valid phone number.
APPLICANT’S AGREEMENT: If necessary, I will take courses required for Certification/Registration by the Ohio Department of Education and/or the Ohio Department of Developmental Disabilities. I understand that these may be college courses and that I will be responsible for payment

YesNo
ATTENTION: READ THE FOLLOWING STATEMENTS BEFORE SIGNING THIS DOCUMENT
As an applicant for employment with the Athens County Board of Developmental Disabilities, I understand that the ACBDD may make a thorough investigation of my past employment and activities through communication with any or all of my former employers listed on my application and any other sources of information that the ACBDD deems appropriate. I hereby authorize ACBDD to make such relative inquiry and investigation of matters that are pertinent to my employment at ACBDD. I reserve the right to request a disclosure of the nature and scope of any inquiry or investigation. Further, I understand and agree that because of the nature of the ACBDD's programs, the ACBDD may require a pre-employment physical examination which may include drug and alcohol screening tests. Examinations will be conducted at the ACBDD’s expense by a physician chosen by the ACBDD and duly licensed by the state. I hereby authorize the release of the results of job- related physical exam to ACBDD.

Pursuant to Ohio Administrative Code Section 5123-2-02, the Athens County Board of Developmental Disabilities is required to conduct background investigations for purposes of employment. Please note that per 5123-2-02, there are five tiers of disqualifying offenses with corresponding time periods that preclude an applicant from being employed with this agency. Therefore, all applicants under final consideration will be required to submit to a background check through the Bureau of Criminal Identification and Investigation. For more information, please review OAC 5123-2-02. Your signature below verifies only that you understand our requirement to conduct background checks following job offers.

In compliance with federal law, all persons hired will be required to verify identity and eligibility to work in the United States and to complete the required employment eligibility verification document form upon hire.

I swear or affirm that the statements in this application are true and correct, and I understand that in the event that false information is discovered and verified, it will be grounds for dismissal. I also understand that all information submitted with my application become property of ACBDD and may not be removed after submission to that office.
Signature

Clear
Signature of Applicant Date

MonthDayYear
Date

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EMPLOYMENT APPLICATION

HIRING PROCESS

PERSONAL INFORMATION

EMPLOYMENT HISTORY - List most recent first. If your job title or duties changed during employment with any one employer, please list as separate employers.

Education

High School

College

Post Graduate

Business or Trade School

Other Education:

CERTIFICATION/LICENSURE/REGISTRATION

References

ATTENTION: READ THE FOLLOWING STATEMENTS BEFORE SIGNING THIS DOCUMENT

Upload any supporting documentation here: