Ohio Presbyterian Retirement Communities Employment Application It is the policy of Ohio Presbyterian Retirement Services to provide equal opportunity in all of its operations and in all areas of employment practice and to assure that there will be no discrimination against any applicant for employment, or employee, because of race, color, religion, sex, age, national origin, ancestry or disability.      General Information  Position applied for: Type of employment desired Full Time Part Time Date available to start: Wages desired: Are you under 18 years of age? Yes No If yes can you provide required proof of your eligibility to work? Yes No Are you a State-Tested Nursing Assistant? Yes No Are you a State-Tested Home Health Aide? Yes No Name (First, Middle, Last): Phone: Current Address: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming How were you referred? Own Accord Employee Advertisement College Placement Service Website Other If Other, please explain: Names of relatives working for Ohio Presbyterian Retirement Services: Position(s): Community: If the answer to any of the following questions is "yes", please explain in the space provided. Have you ever been employed by OPRS? When? Yes No Have you ever been discharged from a position? If so please explain: Yes NO Are you legally eligible to work in the United States? Yes No We employ only United States citizens and non-resident aliens lawfully authorized to work in the United States. In compliance with the Immigration Reform and Control Act of 1986, we require all new employees to complete the employment eligibility verification form (form I-9) and to provide legally sufficient documentation of identity and employment eligibility. Have you pled guilty to or been convicted of a crime other than a driving-related misdemeanor? If yes, explain: Yes No Are you willing to work any assigned days or shifts?: Yes No EDUCATION Last Year of School Completed 1 2 3 4 5 6 7 8 9 10 11 12 College 1 College 2 College 3 College 4 College 5 College 6 College 7 College 8 Technical 1 Technical 2 Technical 3 Technical 4 Name of School, City and State Special Studies Major Subjects Grade Average High School College or University Technical School Other Training SPECIAL SKILLS Typing WPM Shorthand WPM PC WPM Computer Programs WORK EXPERIENCE From: To: Type of employment: Full-time Part-time Summer Temporary Positions held: Description of duties: Employer: Address: Supervisor's name: Employer's Phone Number: Reason for Leaving: From: To: Type of employment: Full-time Part-time Summer Temporary Positions held: Description of duties: Employer: Address: Supervisor's name: Employer's Phone Number: Reason for Leaving: From: To: Type of employment: Full-time Part-time Summer Temporary Positions held: Description of duties: Employer: Address: Supervisor's name: Employer's Phone Number: Reason for Leaving: ADDITIONAL REFERENCES List three unrelated persons known at least two years Name & Relationship Address City and State Years Known Business Telephone CERTIFICATION - READ CAREFULLY I certify that the information provided in this application is complete and accurate to the best of my knowledge. I understand that falsification, misrepresentation or omission of facts in the application will disqualify me from further consideration or, if I am hired, will be sufficient cause for my immediate dismissal. I understand that any employment offer made to me is contingent upon reference checks. I authorize Ohio Presbyterian Retirement Services (the "Company") to investigate, in its discretion, my past employment history, personal references or other types of information provided in this application. I authorize my past employers, all references, and any other persons to answer all questions asked by the Company concerning my education, abilities, and previous employment record. I release all such persons from any and all liability or damages on account of having furnished such information. In connection with my application for employment or with an offer of a position with the Company, I understand that a background and public records check will be made on me. I understand that these checks may include information as to any criminal background, driving records history, job applicable physical, personal reputation, a drug test, finger printing and any other factors which are deemed to be appropriate and proper. I also understand that the Company, or its agent(s), may be requesting this information from various public and private agencies as appropriate. I acknowledge that, in the event of my hire, any employment relationship with the Company is "at will", which means that I may resign at any time and the Company may discharge me at any time with or without cause. I further understand this "at will" employment relationship may not be changed by any written document, by oral statement, or by conduct unless such changes are specifically acknowledged in writing by an authorized executive of the Company.