Anne Grady - Job Application

Name*

First NameLast Name

Date

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Area CodePhone Number

Email*

example@example.com

Have you ever worked under another name?*

YesNo

Have you ever worked for or applied for work with Anne Grady?*

YesNo

Have you resided in Ohio for the last five (5) years?*

YesNo

Have you ever been convicted or plead guilty to a crime (including misdemeanors)?*

YesNo

Have you ever been convicted or plead guilty to a crime (including misdemeanors)?*

YesNo

If a requirement for the position you are applying, can you lift 50 pounds without restriction?

YesNo

Are you at least 18 years of age?*

YesNo

If a requirement for the position you are applying, are you a licensed driver with a car available?

YesNo

If hired, could you present evidence of your U.S. citizenship or proof of your legal right to live and work in this country?*

YesNo

You have reviewed the job description that includes the essential functions of the position for which you are applying. Are you able to perform each of the essential functions listed for the position with or without accommodations?*

YesNo

What accommodations might you need?

Employment Desired:

Available Start Date:

Date

Best Time To Reach You:

Type of Employment Desired*

How did you hear about this position? If referred by current employee, please provide name:*

Most positions at Anne Grady Services require working weekends and holidays. Are you available during these times?*

YesNo

Why do you feel qualified for this position?

Employment History

List all present and past employment, starting with your most recent or current employer. Include military service. You must complete this section even if attaching a resume. Any incomplete information may prevent us from processing your application. Thorough reference checks are conducted.

Position:*

Current or Ending Salary:

Company:*

Phone Number:

Address:

Start Date*

Date

End Date*

Date

Supervisor's Full Name:

Hours Worked Per Week:

Duties:

Reason for Leaving:

Previous Employer

Position:

Current or Ending Salary:

Company:

Phone Number:

Address:

Start Date

Date

End Date

Date

Supervisor's Full Name:

Hours Worked Per Week:

Duties:

Reason for Leaving:

Previous Employer

Position:

Current or Ending Salary:

Company:

Phone Number:

Address:

Start Date

Date

End Date

Date

Supervisor's Full Name:

Hours Worked Per Week:

Duties:

Reason for Leaving:

Education and Training

High School*

School

Street Address

CityState

Postal / Zip Code

Graduate?*

YesNo

College / University

School

Street Address

CityState

Postal / Zip Code

Graduate?

YesNo

Vocational / Business

School

Street Address

CityState

Postal / Zip Code

Graduate?

YesNo

List course of study and/or any other training that makes you especially suited for work at Anne Grady Services:

Upload Your Resume

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PLEASE READ THE FOLLOWING CAREFULLY AND SIGN BELOW.

I CERTIFY THAT ALL ANSWERS GIVEN HEREIN ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE. I AUTHORIZE INVESTIGATION OF ALL STATEMENTS CONTAINED IN THIS APPLICATION FOR EMPLOYMENT AS MAY BE NECESSARY IN ARRIVING AT AN EMPLOYMENT DECISION. I UNDERSTAND THAT A CRIMINAL BACKGROUND INVESTIGATION WILL BE CONDUCTED INCLUDING A DRUG SCREEN AND A PHYSICAL EXAMINATION, AS WELL AS A DOCUMENTED TWO-STEP MANTOUX TEST. ALONG WITH THE SEARCH OF THE FOLLOWING DATA BASES, THE ABUSER REGISTRY; THE NURSE AIDE REGISTRY; THE LIST OF EXCLUDED PERSONS AND ENTITIES; THE SEX OFFENDERS AND CHILD-VICTIM OFFENDERS; THE US GENERAL SERVICES ADMINISTRATION SYSTEM; THE DATA BASE OF INCARCERATED AND SUPERVISED OFFENDERS. I UNDERSTAND THAT ANY OFFER OF EMPLOYMENT IS CONTINGENT UPON SUCCESSFUL COMPLETION OF ALL ENTITIES LISTED ABOVE.

I AUTHORIZE ANNE GRADY SERVICES TO THOROUGHLY INVESTIGATE MY REFERENCES, WORK RECORD, EDUCATION AND OTHER MATTERS RELATED TO MY SUITABILITY FOR EMPLOYMENT AND, FURTHER, AUTHORIZE THE REFERENCES I HAVE LISTED TO DISCLOSE TO ANNE GRADY SERVICES ANY AND ALL INFORMATION RELATED TO MY WORK RECORDS, WITHOUT GIVING ME PRIOR NOTICE OF SUCH DISCLOSURE. IN ADDITION, I RELEASE ANNE GRADY, MY FORMER EMPLOYERS AND ALL OTHER PERSONS, CORPORATIONS, PARTNERSHIPS AND ASSOCIATIONS FROM ANY AND ALL CLAIMS, DEMANDS OR LIABILITIES ARISING OUT OF OR IN ANY WAY RELATED TO SUCH INVESTIGATION OR DISCLOSURE.

I UNDERSTAND THAT NOTHING CONTAINED IN THE APPLICATION OR CONVEYED DURING ANY INTERVIEW THAT MAY BE GRANTED OR DURING MY EMPLOYMENT, IF HIRED, IS INTENDED TO CREATE AN EMPLOYMENT CONTRACT BETWEEN ANNE GRADY SERVICES AND ME. IN ADDITION, I UNDERSTAND AND AGREE THAT IF I AM EMPLOYED, MY EMPLOYMENT IS “AT WILL” AND MAY BE TERMINATED AT ANY TIME, WITH OR WITHOUT PRIOR NOTICE, AT THE OPTION OR EITHER MYSELF OR ANNE GRADY SERVICES, AND THAT NO PROMISES OR REPRESENTATIONS CONTRARY TO THE FOREGOING ARE BINDING ON ANNE GRADY SERVICES UNLESS MADE IN WRITING AND SIGNED BY ME AND ANNE GRADY’S EXECUTIVE DIRECTOR.

I have read, understand and agree to the above terms.*

AgreeDisagree