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Open Hands Of Caring Penn Foundation
[pic]
27059 Center Ridge Road , Westlake Ohio 44145 (440-455-9382)
EMPLOYMENT APPLICATION
(Please print all answers in ink)
Open Hands Of Caring does not discriminate in hiring or employment on the basis of race, color, national origin, religion, sex, or physical or mental disability. All employment decisions will be made solely upon the basis of the individual's qualifications as related to the requirements of the position being filled.
Date______________________________ Social Security Number ____________________________________
Name______________________________________________________________________________________________
Legal Last Legal First Suffix (Jr., III, IV, etc.) Middle
Other names under which you have been employed or attended school __________________________________________
Address_______________________________________________________________________________________ _____
Number Street Apt. # City State Zip Code
Telephone ( )__________________________ (Home) Are you 18 years or older? [pic] Yes [pic] No
( )__________________________ (Mobile)
Email address: __________________________________________
Have you ever been convicted of or pleaded guilty to any offense? All applicants shall disclose a conviction for any offense even if that offense has been sealed.
No I have not Yes I have - Please describe in detail including dates
Please also sign page 10 which states you agree to notify the Director of Staff Services or the Human Resource Manager no later than the next business day if, while in the application process or while employed by the Open Hands, you are is formally charged with, convicted of, or plead guilty to a disqualifying offense or any offense. Failure to make the notification may result in termination of the applicant’s employment or disqualify an applicant from becoming employed.
Are you legally authorized to work in the United States? Yes No
Have you ever lived outside of Ohio in the last five years? Yes No
EMPLOYMENT DESIRED
How were you referred to us? __________________________________________
Position Desired ____________________________________________________
Please check all that are applicable
Full-time______ Part-time______ Temporary ______Weekends ______
Mornings______ Days _________ Evenings _______ Nights ________
Date you can start ___________________________ Salary Desired ____________
EDUCATION
|School |Name |Location |Did you |Degree or Course |
| | | |Graduate? | |
|Accredited High School | | |(Circle) | |
|*Include all attended | | | | |
| | | |Yes | |
| | | | | |
|And / Or | | |No | |
| | | | | |
|GED Program | | |Received | |
| | | |(Circle) | |
| | | | | |
| | | |High School | |
| | | |Diploma | |
| | | | | |
| | | |GED | |
|Business/Technical | | | | |
|Nursing | | | | |
|College | | | | |
|Additional Schooling or Trades | | | | |
Have you previously worked at Open Hands? ______ If yes, dates of employment _________________________
Have you previously applied to Open Hands? ______ If yes, when _____________________________________
WORK HISTORY List present or most recent employer first. Include any periods of military service.
Employer_____________________________________________ Job Title______________________________________
Address_______________________________________________ Telephone number ( )_____________________
City___________________________________ State____________________ Zip Code ___________________________
Dates of Employment ____/_____/_____ to _____/_____/____ Reason for leaving ________________________________
Nature of duties ____________________________________________________________ Salary ___________________
Employer_____________________________________________ Job Title______________________________________
Address_______________________________________________ Telephone number ( )_____________________
City___________________________________ State____________________ Zip Code ___________________________
Dates of Employment ____/_____/_____ to _____/_____/____ Reason for leaving ________________________________
Nature of duties ____________________________________________________________ Salary ___________________
Employer_____________________________________________ Job Title______________________________________
Address_______________________________________________ Telephone number ( )_____________________
City___________________________________ State____________________ Zip Code ___________________________
Dates of Employment ____/_____/_____ to _____/_____/____ Reason for leaving ________________________________
Nature of duties ____________________________________________________________ Salary ___________________
Employer_____________________________________________ Job Title______________________________________
Address_______________________________________________ Telephone number ( )_____________________
City___________________________________ State____________________ Zip Code ___________________________
Dates of Employment ____/_____/_____ to _____/_____/____ Reason for leaving ________________________________
Nature of duties ____________________________________________________________ Salary ___________________
Employer_____________________________________________ Job Title______________________________________
Address_______________________________________________ Telephone number ( )_____________________
City___________________________________ State____________________ Zip Code ___________________________
Dates of Employment ____/_____/_____ to _____/_____/____ Reason for leaving ________________________________
Nature of duties ____________________________________________________________ Salary ___________________
Employer_____________________________________________ Job Title______________________________________
Address_______________________________________________ Telephone number ( )_____________________
City___________________________________ State____________________ Zip Code ___________________________
Dates of Employment ____/_____/_____ to _____/_____/____ Reason for leaving ________________________________
Nature of duties ____________________________________________________________ Salary ___________________
List any periods of unemployment in the spaces provided below:
From:________________ To:____________________ Reason:_______________________________
From:________________ To:____________________ Reason:_______________________________
From:________________ To:____________________ Reason:_______________________________
GENERAL
Subjects of special studies or research ____________________________________________________________________
___________________________________________________________________________________________________
Special Skills________________________________________________________________________________________
__________________________________________________________________________________
REFERENCES
Give the names of three persons not related to you, whom you have known for at least one year.
|NAME |ADDRESS |PHONE |BUSINESS |YEARS KNOWN |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
CERTIFICATION: I certify that the answers given by me to the previous questions and statements are true and without omissions. I authorize Open Hands Of Caring Penn Foundation to investigate the above, and any other information, which might assist in determining any qualifications for employment. I release Open Hands Of Caring Penn Foundation, my former employers, and all others from any liability for damage, which may result from such investigation. If anything contained in this application is found to be untrue, I understand I will be subject to termination at any time during my period of employment or disqualify me from becoming employed. I understand and agree that if hired, my employment is at will and may be terminated at any time without prior notice.
I certify the above is true to the best of my knowledge. ________________________________________________________
SIGNATURE / DATE
Open Hands Of Caring Penn Foundation
4732 Pearl Road
Cleveland Ohio , 44109
I here by authorize Open Hands Of Caring Penn Foundation and also authorize and request former employer and person, firm or corporation given as reference to answer all questions that may be asked. I also authorize and request that they give all information that may be sought in connection with this application, or concerning my work habit, character or my action in any transaction.
SIGNATURE:
DATE:
The FCRA gives several different federal agencies authority to enforce the FCRA:
|FOR QUESTIONS OR CONCERNS |PLEASE CONTACT: |
|REGARDING: | |
|CRA’s creditors and others not listed below |Federal Trade Commission’s |
| |Consumer Response Center – FCRA |
| |Washington, DC 20580 |
| |202-326-3761 |
|National Banks, federal branches/agencies of foreign banks (word “National” |Office of the Comptroller of the Currency |
|or initials “N.A.” appear in or after bank’s name) |Compliance Management, Mail Stop 6-6 |
| |Washington, DC 20219 |
| |800-613-6743 |
|Federal Reserve System member banks |Federal Reserve Board |
|(except national banks, and federal branches/agencies of foreign banks) |Division of Consumer & Community Affairs |
| |Washington, DC 20551 |
| |202-452-3693 |
|Savings associations and federally chartered savings banks (word “Federal” |Office of Thrift Supervision |
|or initials “F.S.B.” appear in the federal institution’s name) |Consumer Programs |
| |Washington, OH 20552 |
| |800-842-2629 |
|Federal credit unions (words “Federal Credit Union” appear in the |National Credit Union Administration |
|institution’s name) |1775 Duke Street |
| |Alexandria, VA 22314 |
| |703-518-6360 |
|State-chartered banks that are not members of the Federal Reserve System |Federal Deposit Insurance Corporation |
| |Division of Compliance & Consumer Affairs |
| |Washington, DC 20249 |
| |800-934-FDIC |
|Air, surface, or rail common carriers regulated by former Civil Aeronautics |Department of Transportation |
|Board or Interstate Commerce Commission |Office of Financial Management |
| |Washington, DC 20590 |
| |202-366-1306 |
|Activities subject to the Packers and Stockyards Act, 1921 |Department of Agriculture |
| |Office of Deputy Administrator – GIPSA |
| |Washington, DC 20250 |
| |202-720-7051 |
A SUMMARY of YOUR RIGHTS
UNDER the FAIR CREDIT REPORTING ACT
The Federal Fair Credit Reporting Act (FCRA) is designed to promote accuracy, fairness, and privacy from information in the files of every “consumer-reporting agency” (CRA). Most CRAs are credit bureaus that gather and sell information about you – such as if you pay your bills on time or have filed bankruptcy – to creditors, employers, landlords, and other businesses. You can find the complete text of the FCRA, 15 U.S.C. 1681-1681u, at the Federal Trade Commission’s website (). The FCRA gives you specific rights, as outlined below. You may have additional rights under state law. You may contact a state or local consumer protection agency or state attorney general to learn those rights.
• You must be told if information in your file has been used against you. Anyone who uses information from CRA to take action against you – such as denying an application for credit, insurance, or employment – must tell you, and give you the name, address, and phone number of the CRA that provided the consumer report.
• You can find out what is in your file. At your request, a CRA must give you the information in your file, and a list of everyone who has requested it recently. There is no charge for the report if a person has taken action against you because of information supplied by the CRA, if you request the report within 60 days of receiving notice of action. You are also entitled to one free report every 12 months upon request if you certify that (1) you are unemployed and plan to seek employment within 60 days, (2) you are on welfare, or (3) your report is inaccurate due to fraud. Otherwise, a CRA may charge you up to eight dollars.
• You must dispute inaccurate information with the CRA. If you tell a CRA that your file contains inaccurate information, the CRA must investigate the items (usually within 30 days) by presenting to its information source all relevant evidence you submit, unless your dispute is frivolous. The source must review your evidence and report its findings to the CRA. (The source also must advise national CRAs—to which it has provided the data—of any error.) The CRA must give you a written report of the investigation, and a copy of your report if the investigation results in any changes. If the CRAs investigation does not resolve the dispute, you may add a brief statement to your file. The CRA must normally include a summary of your statement in future reports. If an item is deleted or a dispute statement is filed, you may ask that anyone who has recently received your report be notified of the change.
• Inaccurate information must be corrected or deleted. A CRA must remove or correct inaccurate or unverified information for its files, usually within 30 days after you dispute it. However, the CRA is not required to remove accurate data from your file unless it is outdated (as described below) or cannot be verified. If your dispute results in any change to your report, the CRA cannot reinsert into your file a disputed item unless the information source verified its accuracy and completeness. In addition, the CRA must give you a written notice telling you it has reinserted the item. The notice must include the name, address and phone number of the information source.
• You can dispute inaccurate items with the source of the information. If you tell anyone—such as a creditor who reports to a CRA—that you dispute an item, they may not then report the information to a CRA without including a notice or your dispute. In addition, once you’ve notified the source of the error in writing, it may not continue to report the information if it is, in fact, an error.
• Outdated information may not be reported. In most cases, a CRA may not report negative information that is more than seven years old; ten years for bankruptcies.
• Access to your file is limited. A CRA may provide information about you only to people with a need recognized by the FCRA—usually to consider an application with a creditor, insurer, employer, landlord, or other business.
• You may chose to exclude your name from CRA list for unsolicited credit and insurance offers. Creditors and insurers may use file information as the basis for sending you unsolicited offers of credit or insurance. Such offers must include a toll-free phone number for you to call if you want your name and address removed from future lists. If you call, you must be kept off the lists for two years. If you request, complete, and return the CRA form provided for this purpose, you must be taken off the lists indefinitely.
• You may seek damages from violators. If a CRA, a user or (in some case) a provider of CRA data, violates the FCRA, you may sue them in state or federal court.
DISCLOSURE REGARDING CONSUMER REPORTS
Please be advised that one or more consumer reports may be obtained by Open Hands Of Caring Penn Foundation for employment purposes prior to any offer of employment (or contract for services) and prior to other employment decisions including decisions regarding protection, reassignment or retention as an employee. These consumer reports may contain information concerning your credit worthiness, credit standing, credit capacity, character, driving record, general reputation, personal characteristics, or mode of living.
Please sign the attached “Consent to Obtaining Consumer Reports” form to indicate that you authorize Open Hands Of Caring Penn Foundation to obtain these reports for employment purposes.
CONSENT TO OBTAINING CONSUMER REPORTS
READ CAREFULLY BEFORE SIGNING
1) I have read the attached “Disclosure Regarding Consumer Reports” and hereby authorize Open Hands to obtain consumer reports concerning me for employment purposes, which purposes include but are not limited to the following: evaluating me for employment, promotion, reassignment or retention as an employee, or any other employment purposes, at all times during the consideration of my employment application and, if hired (or contracted), throughout the duration of my employment. If I am hired (or contracted), this authorization shall remain on file and shall serve as ongoing authorization for Open Hands to procure consumer reports for lawful purposes at any time during my employment (or contact) period.
2) I hereby authorize any present or former employers, consumer reporting agencies, educational institutions, criminal justice agencies, departments of motor vehicles, public agencies, financial institutions, or any other person or agency having knowledge of me to relate information or opinions about myself, including data received from other sources, in order that I may be evaluated for employment purposes. I hereby release these persons and/or organizations from all liability for damages of whatever kind or nature, whether known or unknown, who may at any time accrue to me on account of information, obtained pursuant to this authorization.
SIGNATURE
PRINT YOUR NAME
DATE
Attestation and Agreement to Notify Employer of Disqualifying Offenses
I hereby attest, as an applicant, that I have not been convicted of or pleaded guilty to any of the disqualifying offenses and agree that I will notify Open Hands Of Caring Penn Foundation – either the Director of Staff Services or Human Resource Manager the next business day if while in the application process I am formally charged with, am convicted of, or plead guilty to one of the disqualifying offenses below (page 10) or on the reverse (page 11) of this form OR any offense. I understand that failure to make this notification may result in termination of employment or may disqualify me as an applicant to be hired.
| | | |
|(Employee Signature) |(Employee Printed Name) |(Date) |
Tier 1 Disqualifying Offenses (Permanent Exclusion):
|2903.01 (aggravated murder) |
|2903.02 (murder) |
|2903.03 (voluntary manslaughter) |
|2903.11 (felonious assault) |
|2903.15 (permitting child abuse) |
|2903.16 (failing to provide for a functionally |
|impaired person) |
|2903.34 (patient abuse and neglect) |
|2903.341 (patient endangerment) |
|2905.01 (kidnapping) |
|2905.02 (abduction) |
|2905.32 (human trafficking) |
|2905.33 (unlawful conduct with respect to |
|documents) |
|2907.02 (rape) |
|2907.03 (sexual battery) |
|2907.04 (unlawful sexual conduct with a minor, |
|formerly corruption of a minor) |
|2907.05 (gross sexual imposition) |
|2907.06 (sexual imposition) |
|2907.07 (importuning) |
|2907.08 (voyeurism) |
|2907.12 (felonious sexual penetration) |
|2907.31 (disseminating matter harmful to |
|juveniles) |
|2907.32 (pandering obscenity) |
|2907.321 (pandering obscenity involving a minor)|
|2907.322 (pandering sexually oriented matter |
|involving a minor) |
|2907.323 (illegal use of minor in |
|nudity-oriented material or performance) |
|2909.22 (soliciting/providing support for act of|
|terrorism) |
|2909.23 (making terrorist threat) |
|2909.24 (terrorism) |
|2913.40 (Medicaid fraud) |
|2923.01 (conspiracy) when the underlying offense|
|is any of the offenses or violations on this |
|list |
|2923.02 (attempt) when the underlying offense is|
|any of the offenses or violations on this list |
|2923.03 (complicity) when the underlying offense|
|is any of the offenses or violations on this |
|list |
|A conviction related to fraud, theft, |
|embezzlement, breach of fiduciary |
|responsibility, or other financial misconduct |
|involving a federal or state-funded program, |
|excluding the disqualifying offenses set forth |
|in section 2913.46 of the Revised Code (illegal |
|use of supplemental nutrition assistance program|
|[SNAP] or women, infants, and children [WIC] |
|program benefits). |
|A violation of an existing or former municipal |
|ordinance or law of this state, any other state,|
|or the United States that is substantially |
|equivalent to any of the offenses or violations |
|on this list. |
Tier 2 Disqualifying Offenses (Ten-Year Exclusion):
|2903.04 (involuntary manslaughter) |
|2903.041 (reckless homicide) |
|2905.04 (child stealing) as it existed prior to|
|July 1, 1996 |
|2905.05 (criminal child enticement) |
|2905.11 (extortion) |
|2907.21 (compelling prostitution) |
|2907.22 (promoting prostitution) |
|2907.23 (enticement or solicitation to |
|patronize a prostitute, procurement of a |
|prostitute for another) |
|2909.02 (aggravated arson) |
|2909.03 (arson) |
|2911.01 (aggravated robbery) |
|2911.11 (aggravated burglary) |
|2913.46 (illegal use of supplemental nutrition |
|assistance program [SNAP] or women, infants, |
|and children [WIC] program benefits) |
|2913.48 (workers' compensation fraud) |
|2913.49 (identity fraud) |
|2917.02 (aggravated riot) |
|2923.01 (conspiracy) when the underlying |
|offense is any of the offenses or violations on|
|this list |
|2923.02 (attempt) when the underlying offense |
|is any of the offenses or violations on this |
|list |
|2923.03 (complicity) when the underlying |
|offense is any of the offenses or violations on|
|this list |
|2923.12 (carrying concealed weapon) |
|2923.122 (illegal conveyance or possession of |
|deadly weapon or dangerous ordnance in a school|
|safety zone, illegal possession of an object |
|indistinguishable from a firearm in a school |
|safety zone) |
|2923.123 (illegal conveyance, possession, or |
|control of deadly weapon or dangerous ordnance |
|into courthouse) |
|2923.13 (having weapons while under disability)|
|2923.161 (improperly discharging a firearm at |
|or into a habitation or school) |
|2923.162 (discharge of firearm on or near |
|prohibited premises) |
|2923.21 (improperly furnishing firearms to |
|minor) |
|2923.32 (engaging in pattern of corrupt |
|activity) |
|2923.42 (participating in criminal gang) |
|2925.02 (corrupting another with drugs) |
|2925.03 (trafficking in drugs) |
|2925.04 (illegal manufacture of drugs or |
|cultivation of marihuana) |
|2925.041 (illegal assembly or possession of |
|chemicals for the manufacture of drugs) |
|3716.11 (placing harmful objects in food or |
|confection) |
|A violation of an existing or former municipal |
|ordinance or law of this state, any other |
|state, or the United States that is |
|substantially equivalent to any of the offenses|
|or violations on this list. |
Tier 3 Disqualifying Offenses (Seven-Year Exclusion):
|959.13 (cruelty to animals) |
|959.131 (prohibitions concerning companion |
|animals) |
|2903.12 (aggravated assault) |
|2903.21 (aggravated menacing) |
|2903.211 (menacing by stalking) |
|2905.12 (coercion) |
|2909.04 (disrupting public services) |
|2911.02 (robbery) |
|2911.12 (burglary) |
|2913.47 (insurance fraud) |
|2917.01 (inciting to violence) |
|2917.03 (riot) |
|2917.31 (inducing panic) |
|2919.22 (endangering children) |
|2919.25 (domestic violence) |
|2921.03 (intimidation) |
|2921.11 (perjury) |
|2921.13 (falsification, falsification in theft |
|offense, falsification to purchase firearm, or |
|falsification to obtain a concealed handgun |
|license) |
|2921.34 (escape) |
|2921.35 (aiding escape or resistance to lawful |
|authority) |
|2921.36 (illegal conveyance of weapons, drugs, |
|or other prohibited items onto grounds of |
|detention facility or institution) |
|2923.01 (conspiracy) when the underlying |
|offense is any of the offenses or violations on|
|this list |
|2923.02 (attempt) when the underlying offense |
|is any of the offenses or violations on this |
|list |
|2923.03 (complicity) when the underlying |
|offense is any of the offenses or violations on|
|this list |
|2925.05 (funding of drug or marihuana |
|trafficking) |
|2925.06 (illegal administration or distribution|
|of anabolic steroids) |
|2925.24 (tampering with drugs) |
|2927.12 (ethnic intimidation) |
|A violation of an existing or former municipal |
|ordinance or law of this state, any other |
|state, or the United States that is |
|substantially equivalent to any of the offenses|
|or violations on this list. |
Tier 4 Disqualifying Offenses (Five-Year Exclusion):
|2903.13 (assault) |
|2903.22 (menacing) |
|2907.09 (public indecency) |
|2907.24 (soliciting after positive human |
|immunodeficiency virus test) |
|2907.25 (prostitution) |
|2907.33 (deception to obtain matter harmful to |
|juveniles) |
|2911.13 (breaking and entering) |
|2913.02 (theft) |
|2913.03 (unauthorized use of a vehicle) |
|2913.04 (unauthorized use of property, computer, |
|cable, or telecommunication property) |
|2913.05 (telecommunications fraud) |
|2913.11 (passing bad checks) |
|2913.21 (misuse of credit cards) |
|2913.31 (forgery, forging identification cards) |
|2913.32 (criminal simulation) |
|2913.41 (defrauding a rental agency or hostelry) |
|2913.42 (tampering with records) |
|2913.43 (securing writings by deception) |
|2913.44 (personating an officer) |
|2913.441 (unlawful display of law enforcement |
|emblem) |
|2913.45 (defrauding creditors) |
|2913.51 (receiving stolen property) |
|2919.12 (unlawful abortion) |
|2919.121 (unlawful abortion upon minor) |
|2919.123 (unlawful distribution of an |
|abortion-inducing drug) |
|2919.23 (interference with custody) |
|2919.24 (contributing to unruliness or |
|delinquency of child) |
|2921.12 (tampering with evidence) |
|2921.21 (compounding a crime) |
|2921.24 (disclosure of confidential information) |
|2921.32 (obstructing justice) |
|2921.321 (assaulting/harassing police dog or |
|horse/service animal) |
|2921.51 (impersonation of peace officer) |
|2923.01 (conspiracy) when the underlying offense |
|is any of the offenses or violations on this list|
|2923.02 (attempt) when the underlying offense is |
|any of the offenses or violations on this list |
|2923.03 (complicity) when the underlying offense |
|is any of the offenses or violations on this list|
|2925.09 (illegal administration, dispensing, |
|distribution, manufacture, possession, selling, |
|or using any dangerous veterinary drug) |
|2925.11 (drug possession other than a minor drug |
|possession offense) |
|2925.13 (permitting drug abuse) |
|2925.22 (deception to obtain dangerous drugs) |
|2925.23 (illegal processing of drug documents) |
|2925.36 (illegal dispensing of drug samples) |
|2925.55 (unlawful purchase of pseudoephedrine |
|product) |
|2925.56 (unlawful sale of pseudoephedrine |
|product) |
|A violation of an existing or former municipal |
|ordinance or law of this state, any other state, |
|or the United States that is substantially |
|equivalent to any of the offenses or violations |
|on this list. |
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