Employment Application

Name		Date
Address
City		Zip
Home Phone	-	Cell Phone -
Email

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 sited 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 referred by an employee of Welcome House please specify employee name.
Are you 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.

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Employment Application