Franchise 442 Application Form
Application Form
We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis including race, color, age sex, religion, disability, medical condition, national origin, or marital status.
Office Location
Select Office Location
-- Select Office --
Lorain County
Westlake
Personal Information
First Name
*
Last Name
*
Home Phone
*
Work Phone
Mobile Phone
Email
*
Address 1
*
Address 2
City
*
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*
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--
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Section 1 -
General Information
What days and hours are you available for work?
(required)
Are you available to work every other weekend?
(required)
Yes
No
Are you legally eligible to work in the United States? (Proof of eligibility is required)
Yes
No
Applicants considered for hire will be subject to a thorough background screening process that includes a criminal background check, and may include a credit check, motor vehicle check and drug screen. (Please note that some positions require you to be insured and bonded.) Please check if in agreement:
Yes
No
Do you have a valid driver's license and reliable transportation?
Yes
No
Have you ever been convicted of a felony?
Yes
No
If yes, please list charge and date of conviction:
Are you able to perform the essential functions of the job for which you are applying, with or without reasonable accommodations?
Yes
No
If no, describe the functions that cannot be performed:
Have you been a resident in Ohio for the last 5 years?
(required)
Yes
No
If no, where did you reside prior to living in Ohio?
Do you have your HHA/STNA certification?
(required)
Have you ever been known by any other name? (ie. maiden name, alias, etc.)
(required)
Yes
No
If so, what other names have you gone by?
(required)
Section 2 -
Educational Background
Type of School (High School/GED/College)
Name/City
Graduated
Yes
No
Section 3 -
1st Most Recent Employer
Employer:
Address:
City:
State:
Zip Code:
Start Date:
End Date:
Position/Title:
Supervisor's Name/Title:
Supervisor's Phone:
May we contact?
Yes
No
Section 6 -
Reference 1
Name:
Telephone:
Years Known:
Relationship:
Section 7 -
Reference 2
Name:
Telephone:
Years Known:
Relationship:
Section 8 -
Reference 3
Name:
Telephone:
Years Known:
Relationship:
Section 9 -
Emergency Contact
Full Name
(required)
Phone Number
(required)
Address, City, & Zip
(required)
I certify that information contained in this application is true and complete. I understand that false information may be grounds for not hiring me or for immediate termination of employment at any point in the future if I am hired. I authorize the verification of any or all information listed above.
Signature
Submit Application