Employment Opportunities

Employment Application

MARYHAVEN IS AN EQUAL OPPORTUNITY EMPLOYER AND SERVICE PROVIDER

Applicants are considered for all positions without regard to race, color, religion, sex, sexual orientation, national origin, age, marital status, status as a Vicmam Era veteran, handicap, developmental disability, HIV infection or AIDS.

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  LAST FIRST MIDDLE INITIAL
Name  
  STREET    
Mailing Address  
  CITY STATE ZIP
 
Phone   
Email   
SSN   

Date of Application   
Position(s) Applied For (Include Position Control Number)   
1.
2.

Referral Source    Advertisement
  Walk-In
  Employee Referral
  Other

Have you ever been employed here before?   Yes    No
If yes, give date  
Are you employed now?   Yes    No

When are you availble to work?           Days 
           Nights 
           Full Time 
           Part Time 
           Shift Work 
           Temporary 
Days and hours available a.m.             
  p.m.             

Do you have written verification of the right to work in the U. S.?   Yes    No
Are you 18 years of age or older?   Yes    No
Do you have a valid Ohio Driver's License?   Yes    No
Can you drive if the job requires?   Yes    No

List any relative working for us and his or her relationship to you

Have you ever been convicted of a crime other than a traffic related misdemeanor?   Yes    No

Additional Comments  

EDUCATIONAL BACKGROUND

  Elementary High School College / Univ Post Graduate
School Name        
Years Completed  
Year Graduated        
Diploma / Degree        
Course Of Study      

ACADEMIC AND PROFESSIONAL ACTIVITIES AND ACHIEVEMENTS

Include academic and professional activities and achievements, awards, publications or technical-professional societies. Indicate type or name. Inclusion of organizations which indicate race, creed, color, sex, religion, handicap, national origin or sexual orientation is voluntary.


SPECIAL SKILLS

List all office equipment and level of competency (Expert/Proficient/Beginner)


List all computer software and level of competency (Expert/Proficient/Beginner)


List any languages and level of competency (Expert/Proficient/Beginner) as well as skill areas (Written/Spoken)

MISCELLANEOUS

List any additional information, skills or experience that relate to the position for which you are applying.


EMERGENCY INFORMATION
Person to be notified in case of emergency
Full Name Address Phone Number Relationship to you?
Place of Employment Address Phone Number
 


EMPLOYMENT HISTORY

List in order, last or present employer first. Please fill in ALL spaces.
EMPLOYER 1
Employer Dates Position / Title Wages
Address City State ZIP Phone Number
Supervisor Reason for Leaving Duties Performed

EMPLOYER 2
Employer Dates Position / Title Wages
Address City State ZIP Phone Number
Supervisor Reason for Leaving Duties Performed

EMPLOYER 3
Employer Dates Position / Title Wages
Address City State ZIP Phone Number
Supervisor Reason for Leaving Duties Performed

EMPLOYER 4
Employer Dates Position / Title Wages
Address City State ZIP Phone Number
Supervisor Reason for Leaving Duties Performed

APPLICANT'S CERTIFICATION AND AGREEMENT
Please Read Carefully

I hereby affirm that the information given by me on this application for employment is complete and accurate. I understand that any falsification or omission will be grounds for immediate dismissal or refusal to employ. I authorize a thorough investigation to be made in connection with this application including a criminal record check. I hereby authorize a release of documents to and authorize of third parties in order to effect a thorough background investigation. I authorize all persons who have information relevant to this investigation to disclose it to the Agency or its agents and I release all such persons from liability on account of such disclosure. I understand and agree that if employed, my employment will be "at will" that is, I can be terminated with or without cause, and without notice, at any time, at the option of Maryhaven or myself.

 I Agree



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