Anne Grady

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First Name:*
Middle:*
Last:*
Date
Address:*
Home Phone:
-
Cell Phone:
-
Have you ever worked under another name:*
If yes, what name?
Have you ever worked for or Applied for work with Anne Grady?*
If so, when?
Have you resided in Ohio for the last five(5) years?*
If not, what county/state have you resided?
Have you ever been convicted or plead guilty to a crime (including misdemeanors)*?*
If yes, when and for what offense?
If a requirement of the position you are applying, can you lift 50 pounds without restrictions?*
Are you atleast 18 years of age?*
If a requirement for the position you are applying, are you a licensed driver with a car available?*
If hired, could you present evidence of your U.S. citizenship or proof of your legal right to live and work in this country?*
You have reviewed the job description that includes the essential functions of the postion for which you are applying. Are you able to perform each of the essectial functions listed for the postion with or without accomodations?*
What accomodations might you need?
Employment Desired:
Date Available to Start:
 / 
 / 
Best Time To Reach You:
Type of Employment Desired:*
How did you hear about the position? If referred by a current employee, please provide name:*
Most positions at Anne Grady Services require working weekends and holidays. Are you available during these times?*
Why do you feel qualified for this position?

Employment History
List all present and past employment, starting with your most recent or current employer. Include military service. You must complete this section even if attaching a resume. Any incomplete information may prevent us from processing your application. Thorough reference checks are conducted.

Most Recent or Current Employer

Position:
Current or Ending Salary:
Company:
Telephone #
-
Address :
Date Start:
Date End:
Supervisor’s Full Name:
Hours Worked Per Week:
Duties:
Reason for Leaving:

Previous Employer

Position:(1)
Current or Ending Salary:(1)
Company:(1)
Telephone #(1)
-
Address :(1)
Date Start:(1)
Date End:(1)
Supervisor’s Full Name:(1)
Hours Worked Per Week:(1)
Duties:(1)
Reason for Leaving:(1)

Previous Employer

Position:(2)
Current or Ending Salary:(2)
Company:(2)
Telephone #(2)
-
Address :(2)
Date Start:(2)
Date End:(2)
Supervisor’s Full Name:(2)
Hours Worked Per Week:(2)
Duties:(2)
Reason for Leaving:(2)

Education and Training

High School:*
Graduate?*
College/University:
Graduate?(1)
Vocational/Business:
Graduate?(1)(1)
List course of study and/or any other training that makes you especially suited for work at Anne Grady Services:

References
Please list three people who are not related to you whom we may contact as references.

1. Name:
1. Address:
1. Relationship:
1. Phone #
-
1. Known How Long?
2. Name:
2. Address:
2. Relationship:
2. Phone #
-
2. Known How Long?
3. Name:
3. Address:
3. Relationship:
3. Phone #
-
3. Known How Long?

Please Read The Following Carefully and Sign Below


I certify that all answers given herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. I understand that a criminal background investigation will be conducted including a Drug screen and a physical examination, as well as a documented two-step mantoux test. Along with the search of the following data bases, The abuser registry; The nurse aide registry; The list of excluded persons and entities; The sex offenders and child-victim offenders; The US general services administration system; The data base of incarcerated and supervised offenders. I understand that any offer of employment is contingent upon successful completion of all entities listed above.
I authorize Anne Grady Services to thoroughly investigate my references, work record, education and other matters related to my suitability for employment and, further, authorize the references I have listed to disclose to Anne Grady Services any and all information related to my work records, without giving me prior notice of such disclosure. In addition, I release Anne Grady, my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure.
I understand that nothing contained in the application or conveyed during any interview that may be granted or during my employment, if hired, is intended to create an employment contract between Anne Grady Services and me. In addition, I understand and agree that if I am employed, my employment is “at will” and may be terminated at any time, with or without prior notice, at the option or either myself or Anne Grady Services, and that no promises or representations contrary to the foregoing are binding on Anne Grady Services unless made in writing and signed by me and Anne Grady’s Executive Director.

I have read, understand and agree to the above terms.*

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1525 Eber Road
Holland, Ohio 43528

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