Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Position Applying For

Available Full Time?

Yes

Are you legally eligible?

Yes

How did you learn about this opening?

Have you been employed by the board in the past?

Yes

Do you have relatives that work for the board?

Yes

Education History

High School Name and City

Graduate High School?

Yes

College Name

College Degree

College Major

Graduate from College

Yes

Post Graduate School

Post Degree

Post Major

Graduated Post

Yes

Business or Trade School

Business Degree

Business School Graduate

Yes

Certification/Licensure/Registration

For many positions, state certification, licensure or registration requirements MUST be met. Be sure to enclose copies of the applicable document(s) and complete the information below as it relates to the position(s) for which you have applied. Applicants who are do not currently hold the required credential for a given position may be eligible for a temporary credential if offered the position. Applicants accepting a position with a temporary credential must meet the course work, training, or other requirements for the renewal or upgrading of the credential in order to remain eligible for employment with the Board.

Certification or Registration from the Ohio Department of Developmental Disabilities

Certification Type

Expiration Date

Additional Certification

Please list other certificates, registrations or licenses that you have that are required for the position(s) for which you applied. Include Type, Authorizing body and expiration date.

Employment History

List most recent first. If your job title or duties changed during employment with any one employer, please list as separate employers. Use an additional sheet of paper, if necessary, but include only the information requested below. ORC 4506.20(A) A resume may not be used as a substitute for completing this application form.

Employer 1

Job Title

Dates of Employment

Direct Responsibilities

Employer 2

Job Title

Dates of Employment

Direct Responsibilities

Employer 3

Job Title

Dates of Employment

Direct Responsibilities

Military Service

Branch of Service

Period of Active Duty

Rank at Discharge

Final Discharge Status

Describe your duties and any specialized Training

Miscellaneous

Can you perform the essential functions of the specific job(s) for which you are applying as listed in the Position Description, with or without a reasonable accommodation?

Yes

Have you ever been discharged or requested to resign from a position?

Yes

If Yes, please explain:

Have you ever had a certificate, license or registration revoked or suspended?

Yes

If Yes, please explain:

Have you ever been bonded?

Yes

If Yes, with what employer?

References

Reference #1 Name

First Name

Last Name

Reference #1 Phone

(###)

###

####

Reference #1 Occupation

Reference #2 Name

First Name

Last Name

Reference #2 Phone

(###)

###

####

Reference #2 Occupation

Reference #3 Name

First Name

Last Name

Reference #3 Phone

(###)

###

####

Reference #3 Occupation

Notice of Requirements of Criminal History Background Check

The Knox County Board of Developmental Disabilities is mandated by law to conduct criminal background checks on applicants under final consideration for employment. If you are a finalist, you will be required to complete an affidavit and be fingerprinted. The background check will be completed by the Bureau of Criminal Investigation & Identification and, if applicable, the Federal Bureau of Investigation. All offers of employment are contingent upon satisfactory reports. Disclosure of a criminal record will not necessarily disqualify you for employment. Each conviction will be evaluated on its own merits with respect to time, circumstances and seriousness of the offense in relation to the job for which you are applying. The report is not subject to the Ohio Public Records Act. Upon request, you will be given a copy of the report.

Additional Information

Please summarize other experiences, skills, or qualifications that you feel would qualify you for the position(s) for which you have applied

Applicants Agreement

I certify that I have read and understand the instructions and all other information for this application and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentations of fact called for in this application may result in the rejection of my application or immediate discharge at any time during my employment. I understand that, as a condition of initial or continued employment, I agree to such lawful examinations, medical or substance abuse, or others as may be required by the Board. I authorize the Board and/or its agents, including consumer reporting bureaus, to verify any of this information by searching appropriate information and record sources. I authorize all employers (unless employers are specifically restricted in Employment History section of this application), persons, schools, companies, law enforcement authorities and state agencies to release any information concerning my background and hereby release those parties from any liability for any damage whatsoever for issuing this information. I confirm that I meet all the requirements as stated on the job posting(s) for the position(s) for which I am applying. I am also able to perform all the essential duties of the position(s) as listed in the Position Description(s). I understand and agree that, as a condition of employment, I shall meet and maintain all required standards of my position that involve certification, registration, licensure and training. I further understand that I may be required to enroll in college courses and/or other training on my own time and at my own expense. I grant permission to have this application and its enclosures to be duplicated and distributed to the Board’s employees responsible for initial screening, interviewing and recommending applicants for employment and to employees responsible for personnel records and reports.*

I agree to the terms and conditions above

Yes

Employment Application

Knox County BOARD OF DEVELOPMENTAL DISABILITIES ONLINE APPLICATION