APPLICATION / NEW HIRE CHECKLIST
(All items must be placed in the employee's personnel record)
PRE-EMPLOYMENT ORIENTATION
1. Application completed (includes):
2. Application Form and Addendum
3. Verification of Licensure/Certification
4. Resume with Experience and List of Competencies
5. I-9 Documents (work authorization, if required, photo ID) *
*
6. Health screening (TB, Hepatitis B, Physicals) results*
*
7. Satisfactory BCI / FBI Background Check*
*
8. Reference Check
9. Valid OHIO Driver's License
10. CPR Certificate
11. Other:
My signature below verifies that I have received all the required documents to complete my application, that I have participated in the above orientation session and received all information required to carry out my duties for the position for which I was hired.
Employee Printed Name:
Signature:
Date:
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Month
-
Day
Year
Date
Staff Printed Name & Title:
Signature:
Date:
-
Month
-
Day
Year
Date
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An Equal Opportunity Employer
We are committed to providing equal employment opportunities to all applicants and employees without regard to race, color, religion, national origin, sex, age, disability, or any other status protected by law. Selection decisions are based on qualifications, merit, and business needs.
Applicant Information
Full Name:
First Name
Last Name
Street Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number:
Format: (000) 000-0000.
Email Address:
example@example.com
Date of Application:
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Month
-
Day
Year
Date
Social Security Number (SSN):
Date of Birth (DOB):
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Month
-
Day
Year
Date
Position Applied For:
Prior Facility History
Have you applied to this facility before?
Yes
No
If yes, when?
Have you been employed by this facility before?
Yes
No
If yes, when?
Legal and Employment Status
Have you been convicted of a law violation? (Exclude minor traffic violations.)
Yes
No
If yes, provide details:
Will you engage in other employment or business while working here?
Yes
No
If yes, provide details:
Do you have a valid driver's license?
Yes
No
License Number:
Class:
State:
Have your driving privileges been suspended or revoked in the past three years?
Yes
No
If yes, provide details:
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Education
College / University
School Name & Location:
Years Completed:
Degree/Certificate:
Field of Study:
Vocational / Technical School
School Name & Location:
Years Completed:
Degree/Certificate:
Field of Study:
Skills and Equipment Proficiency
Relevant Skills or Training:
Machines/Equipment Operated:
Employment History
(List periods of employment starting with the most recent)
[Position [1]
Employer Name & Address:
Job Title & Duties:
Dates of Employment (From - To):
Pay (Start/Final):
Supervisor Name & Contact:
Reason for Leaving:
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[Position [2]
Employer Name & Address:
Job Title & Duties:
Dates of Employment (From - To):
Pay (Start/Final):
Supervisor Name & Contact:
Reason for Leaving:
[Position [3]
Employer Name & Address:
Job Title & Duties:
Dates of Employment (From - To):
Pay (Start/Final):
Supervisor Name & Contact:
Reason for Leaving:
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Acknowledgment and Consent
PLEASE READ EACH STATEMENT CAREFULLY BEFORE SIGNING
1. I certify that all the information provided in this employment application is true and complete. I understand that any false information or omission may disqualify me from further consideration for employment and may result in my dismissal if discovered later.
2. I authorize the investigation of any or all statements contained in this application. I also authorize, whether listed or not, any person, school, current employer, past employers, and organizations to provide relevant information and opinions that may be useful in making a hiring decision. I release such people and organizations from any legal liability in making such statements.
3. I understand that I may be required to successfully pass a drug screening examination. I hereby consent to a pre- and/or post-employment drug screen as a condition of employment, if required.
4. I understand that if I am extended an offer of employment, it may be conditioned upon my successfully passing a complete pre-employment physical examination. I consent to the release of any or all medical information as may be deemed necessary to judge my capability to perform the work for which I am applying.
5. I UNDERSTAND THAT THIS APPLICATION, VERBAL STATEMENTS BY MANAGEMENT, OR SUBSEQUENT EMPLOYMENT, DOES NOT CREATE AN EXPRESS OR IMPLIED CONTRACT OF EMPLOYMENT NOR GUARANTEE EMPLOYMENT FOR ANY DEFINITE PERIOD OF TIME. I UNDERSTAND THAT IF HIRED, EMPLOYMENT IS AT THE WILL OF THE EMPLOYER AND MAY BE TERMINATED AT ANY TIME, WITH OR WITHOUT REASON AND WITH OR WITHOUT NOTICE.
I have read, understand, and consent to these statements.
Signature of Applicant:
Printed Name:
Date:
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Month
-
Day
Year
Date
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