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2. HILLSIDE COUNTRY LIVING

   HILLSIDE COUNTRY LIVING

   Thank you for choosing Hillside Country Living, an Equal Opportunity Employer, as your employment opportunity.

   Before completing this application, please pay special attention to the following:

   • Hillside DOES NOT participate with the Social Security program.  Our form of retirement is thru the Ohio Public Employees Retirement System (OPERS.)

   • Please read and sign the statement regarding LONG TERM CARE WORKERS BACKGROUND CHECK (Senate Bill 160) along with the DISQUALIFYING OFFENSES.

4. CANIDATE INFORMATION
6. Position Applying for:*
   -- Select One --NURSE NURSING ASSISTANTFOOD SERVICE ENVIRONMENTAL SERVICES ACTIVITIESASSISTED LIVING
7. Were you ever employed by this facility?*
   -- Select One --YesNo
9. What deparrtment?
10. When were you employed at Hillside?
    When were you employed at Hillside? Start Date

    —

    When were you employed at Hillside? End Date
12. First Name*
13. Middle Initial
14. Last Name*
16. Are you over 18 years of age?*
    -- Select One --YesNo
17. Maiden / Other Name
19. Current Address*
21. Cell Phone*
22. Home Phone
23. Email Address*
25. In case of an emergency provide a contact:*
27. Relationship to Contact*
28. Contact's Cell Number*
30. EMPLOYMENT HISTORY

    In this section, list all employment history and work experience in date order. Begin with the most current employer. Attach additional information if necessary. Failure to include all employment may be grounds for disqualification.

32. Employer
33. Currently Employed

    1. Yes
    2. No
35. Business Address
36. May we contact employer;
    -- Select One --YesNo
38. Business Phone
39. Supervisor
40. Job Title
42. Employment Dates
    Employment Dates Start Date

    —

    Employment Dates End Date
44. Beginning Pay Rate
45. Rate Per
    -- Select One --HourPay PeriodAnnual
46. Ending Pay Rate
47. Rate Per
    -- Select One --HourlyPay PeriodSalary
49. Describe duties, responsibilities, equipment operated, promotions, etc.
51. Why do (did) you want to leave?
53. Additional Employment History
57. EDUCATION AND TRAINING

    This section is intended to give the employer information about the education and training that the applicant has completed and to demonstrate the skills, knowledge and abilities of the applicant to perform the job duties of the position.

59. High School Attended
61. Did you graduate?
    -- Select One --YesNo
62. High school equivalent?
    -- Select One --YesNo
64. Trade School or College Attended
66. Did you graduate?
    -- Select One --YesNo
67. Degree(s) or Certification(s)
69. FURTHER CANIDATE DETAILS
71. Are there commitments that may interfere with or affect your employment if hired?

    Such as another job, school, etc

72. commitments
    -- Select One --YesNo
74. If yes, please explain
76. Do you possess a valid driver's license?*
    -- Select One --YesNo
77. If no, can you obtain one prior to employment?
    -- Select One --YesNo
79. Are you related to anyone who is employed by Williams County?*
    -- Select One --YesNo
80. Are you eligible to work in the US?*
    -- Select One --YesNo
82. Are you a resident of Ohio?*
    -- Select One --YesNo
83. If yes, how long?
84. Year(s)
85. Month(s)
87. REFERENCES

    Please provide the names and contact number for three (3) people, not related to yourself, that you have known for at least one (1) year.

89. Contact #1*
90. Phone*
92. Contact #2*
93. Phone*
95. Contact #3*
96. Phone*
98. Agree to accurate info

    I AFFIRM THAT ALL OF THE INFORMATION FURNISHED IN THIS EMPLOYMENT APPLICATION IS TRUE, ACCURATE AND COMPLETE TO THE BEST OF MYKNOWLEDGE. I AUTHORIZE INVESTIGATION OF ALL STATEMENTS CONTAINED IN THIS APPLICATION. I UNDERSTAND THAT ANY MISREPRESENTATION OR FALSIFICATION OF THE INFORMATION PROVIDED. MAY LEAD TO WITHDRAWAL OF AN EMPLOYMENT OFFER OR TERMINATION FOLLOWING EMPLOYMENT. I RECOGNIZE THAT MY FUTURE EMPLOYMENT WITH THE EMPLOYER WILL BE JEOPARDIZED IF I ENGAGE IN SUBSTANCE ABUSE, ILLEGAL DRUG USE, OR ALCOHOL ABUSE.

    1. I affirm
100. LONG TERM CARE WORKERS BACKGROUND CHECK (AM. SUB. SENATE BILL 160)

102. CONSENT AND ATTESTATION FORM

     By signing this form, I consent to the submission of a request for a criminal records check for long-term care workers as required by S.B. 160. The request will be submitted by Williams County Hillside Country Living. Proof of Ohio residency for the past 5 years is required for verification purposes (i.e., State income tax returns, school records.) This must be provided at the time your physical is returned. I also attest to the following:

     1. That I have not been conficted of or plead guilty to any of the crimes that would disqualify me from working with older adults under S.B. 160 **See List Below**
     2. That I understand and agree that if I am found to have a record of any of those crimes, I will not be hired for work with older adults or if I have already been hired, my employment will be terminated.
     3. That I was informed that I must provide a set of fingerprint impressions and that a criminal records check must be conducted if I come under final consideration for employment.
104. Electronic Signature Agreement*

     By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

     1. I agree.
106. Electronic Signature*
108. DISQUALIFYING OFFENSES

110. Am. Sub. Senate Bill 160 Criminal Record Checks (Effective January 27, 1997)

     
     

     2903.01 Aggravated Murder

     2903.02 Murder

     2903.03 Voluntary Manslaughter

     2903.04 Involuntary Manslaughter

     2903.11 Felonious Assault

     2903.12 Aggravated Assault

     2903.13 Assault

     2903.16 Failing to Provide for a Functionally Impaired Person

     2903.21 Aggravated Menacing

     2903.34 Patient Abuse and Neglect

     2905.01 Kidnapping

     2905.02 Abduction

     2905.04 Child Stealing

     2905.05 Criminal Child Enticement

     2905.11 Extortion

     2905.12 Coercion

     2907.02 Rape

     2907.03 Sexual Battery

     2907.04 Corruption of a Minor

     2907.05 Gross Sexual Imposition

     2907.06 Sexual Imposition

     2907.08 Voyeurism

     2907.09 Public Indecency

     2907.12 Felonious Sexual Penetration

     2907.21 Compelling Prostitution

     2907.22 Promoting Prostitution

     2907.23 Procuring

     2907.25 Prostitution

     2907.31 Disseminating Matter Harmful to Juveniles

     2907.32 Pandering Obscenity

     2907.32.1 Pandering Obscenity Involving a Minor

     2907.32.2 Pandering Sexually Oriented Matter Involving a Minor

     2907.32.3 Illegal Use of Minor in Nudity-oriented Material or Performance

     2911.01 Aggravated Robbery

     2911.02 Robbery

     2911.11 Aggravated Burglary

     2911.12 Burglary

     2911.13 Breaking and Entering

     2913.02 Theft: Aggravated Theft

     2913.03 Unauthorized Use of a Vehicle

     2913.04 Unauthorized Use of Property; Unauthorized Access to Computer System

     2913.11 Passing Bad Checks

     2913.21 Misuse of Credit Cards

     2913.31 Forgery

     2913.40 Medicaid Fraud

     2913.43 Securing Writings by Deception

     2913.47 Insurance Fraud

     2913.51 Receiving Stolen Property

     2919.12 Unlawful Abortion

     2919.22 Endangering Children

     2919.24 Contributing to Unruliness or Delinquency of a Child

     2919.25 Domestic Violence

     2921.36 Prohibition of Conveyance of Certain Items on to Grounds of Detention Facility or Mental Health or MRDD Facility

     2923.12 Carrying Concealed Weapons

     2923.13 Having Weapons While Under Disability

     2923.16.1 Improperly Discharging Firearm at or into Habitation or School

     2925.02 Corrupting Another With Drugs

     2925.03 Trafficking in Drugs

     2925.04 Shall Not Cultivate or manufacture drugs

     2926.05 Shall Not Provide Money to Another if the Recipient is to Use the Money to Purchase Any Controlled Substance

     2925.06 Shall Not Administer, Prescribe, or Dispense any Anabolic Steroid Not Approved by US FDA.

     2925.11 Drug Abuse, Shall Not Obtain, Possess or Use a Controlled Substance

     2925.13 Permitting Drug Abuse

     2925.22 Deception to Obtain Dangerous Drugs

     2925.23 Illegal Processing of Drug Documents

     3716.11 Adulterated Food

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