Job Application

Name Date
Address
City         
Zip
Home Phone Cell Phone  
Email Best time to be contacted
   
Are you a citizen of the United States or legal immigrant? Yes No 
Are you at least 21 years old? Yes No 
Do you possess a valid Ohio drivers license? Yes No 
Have you had a drivers license for at least 3 years? Yes No 
Have you been cited for any traffic violations in the last 3 years? Yes No 
If needed, can you supply transportation for work use? Yes No 
Do you have automobile insurance? Yes No 
Have you ever been arrested, plead guilty to, or convicted of any offense? Yes No 
Have you ever been terminated or asked to resign from a job? Yes No 
Are you on layoff? Yes No 
Subject to recall? Yes No 
What Position are you applying for?
Have you ever applied for employment with Welcome House? Yes No 
How did you learn about our agency? If from an employee
of Welcome House please enter their name.
Currently Working? Yes No 
If currently working: Where?
If currently working: How long?
Date that you are available for employment:
Wages required: $ Per Preferred hours/shift
Are you interested in: Full Time Part Time Weekends Only On Call 
Would you be willing to work extra hours if asked to do so? Yes No 

What work experience, Intellectual and Developmental Disabilities (IDD) experience, volunteer experience, education, skills, talents or hobbies do you have that you feel may be incorporated into your duties if you were to be hired by Welcome House?

I (the applicant) understand and agree that the information provided is truthful and accurate.

I understand and agree that by submitting this form, allows Welcome House to verify the information provided. If I have misrepresented or omitted any information on this application, and are subsequently hired, it may be grounds for dismissal.

I may be required to supply my birth certificate or other proof of authorization to work in the US, have a physical examination and/or a drug test, or to sign a conflict of interest agreement and abide by its terms.

Welcome House is an Equal Opportunity Employer.