ST. STEPHEN’S COMMUNITY HOUSE
1500 East 17th Avenue * Columbus, Ohio 43219 * (614) 294-6347
_
APPLICATION FOR EMPLOYMENT_
Name (in full)Date
Current Address
(House Number, Street
City, State, Zip Code)
Former Address
(If less than one year at above)
Home Phone Cell Phone Business Phone
include area code)
Email Address
_GENERAL INFORMATION_
Social Security Number For what position are you applying?
Check All That Apply Part Time Full Time Intern Temporary
Are you 18 years or older? _____Yes _____No Ohio Driver’s License #
What hours are you available? Mornings Evenings All Day
When are you available to start if hired for a position?
Are you willing to travel within a 20 miles radius during work hours?_____Yes _____No
Have you ever supervised other people in a work environment? _____Yes _____No If yes, for how many years?
On average, how any people did you directly supervise at any given time?
Have you ever applied for a job at St. Stephen’s prior to this application? _____Yes _____No
Have you been employed by St. Stephen’s prior to this application? _____Yes _____No If yes, list dates of employment, job description, supervisor, and why you left the agency.
How did you learn about this job posting? If referred by a current or previous employee, please list their name.
Why do you want to work for St. Stephen's Community House?
ARE YOU AUTHORIZED FOR EMPLOYMENT IN THE U.S.?_____Yes _____No …. We will hire only those persons who are authorized by law to work in the United States. Any offer of employment, if made, will be conditioned upon your production of documentation to prove your employment eligibility status under the IMMIGRATION REFORM AND CONTROL ACT OF 1986._
Have you ever been convicted of or pled guilty to a crime? _____Yes _____No …If yes, please explain (Include: Nature of offense, date of conviction or guilty plea, penalty imposed, County, State or other relevant circumstances). Conviction or a guilty plea is not an automatic bar to employment; all circumstances will be considered.
LICENSURE
Please list any current and valid professional licenses or certifications you currently hold (LSW, LPC, LISW, CCDCIII, CDL, CPR,etc). Please note:if an offer of employment is made, you will be asked to provide copies of your licenses and certifications.
List current and valid licenses and/or certifications here:
Have you ever applied for and been denied a professional license, registration or certification?_____Yes _____No
If yes, please explain:
Have you ever had a professional license, registration or certification revoked?_____Yes _____No
If yes, please explain:
Note: Denial, suspension or revocation of a professional license, registration or certification is not an automatic bar to employment; all circumstances will be considered.
EDUCATION
___
Training / Name of School / City/State / Area of Study/Type of Courses / Underline Last Year Completed / Did you Graduate?
High
School / . / Years:
9 10 11 12
Business
School / 1 2 3 4
College or
University / 1 2 3 4 / Degree Received
Additional
Schooling / 1 2 3 4
SPECIAL SKILLS
Are you an experienced computer user? _____Yes _____No
Indicate your level of proficiency with each of the following:
Word / N/A / Beginner / Intermediate / Advanced UserExcel / N/A / Beginner / Intermediate / Advanced User
Outlook / N/A / Beginner / Intermediate / Advanced User
Power Point / N/A / Beginner / Intermediate / Advanced User
Publisher / N/A / Beginner / Intermediate / Advanced User
Other Software (please list):
Beginner / Intermediate / Advanced UserBeginner / Intermediate / Advanced User
Beginner / Intermediate / Advanced User
Beginner / Intermediate / Advanced User
EXPERIENCE REFERENCES
Are you currently employed? ______Yes ______No
May we contact your current employer? ______Yes ______No
DatesFrom / To
Mo. / Yr. / Mo. / Yr. / Name of Company / Address and Phone Number / Name of Supervisor
1.
2.
3.
4.
Give Title and Nature of Work / Monthly Earnings / Reason for Leaving
1.
2.
3.
4.
Have you ever been terminated or asked to resign from any employment? ______Yes ______No If yes, please explain:
CHARACTER REFERENCES
(DO NOT INCLUDE PREVIOUS EMPLOYERS OR RELATIVES; SPECIFY HOW LONG YOU HAVE KNOWN THE REFERENCE. PLEASE DO
NOT LIST REFERENCES THAT YOU HAVE KNOWN FOR LESS THAN ONE YEAR.)
1.
2.
3.
4.
IF SOMEONE OTHER THAN THE APPLICANT COMPLETED THIS FORM, PLEASE COMPLETE CONTACT INFORMATION BELOW:
Name: _
Phone number where they can be reached:______
Email address (if available) where theycan be reached:
ACKNOWLEDGEMENT
I acknowledge that the foregoing information is true and complete to the best of my knowledge, and that if not it may result in my application being disregarded from consideration. I understand that, if employed, any misrepresentation, false statement or omission later discovered will be grounds for termination.
I authorize St. Stephen's Community House to investigate my employment record and background, including criminal conviction records and credit check, and I hereby release and hold St. Stephen's Community House and all parties who provide such records or information harmless from all liabilities arising from such disclosures. I understand that, if I receive a conditional offer of employment, I may be required to undergo a drug or alcohol screen, and I agree to take such test. I understand that if I am hired, St. Stephen's Community House may require me to undergo drug or alcohol testing within the guidelines of its personnel practices, participation in any Ohio Bureau of Workers' Compensation drug-free workplace program, or to the extent permitted by law, and I agree to cooperate in such testing. I understand that St. Stephen's Community House maintains a smoke-free environment and may restrict employee smoking while on agency business. I understand that refusal to do so may result in immediate termination. I understand that, if hired, my employment is at will,
which means that either I or the company may terminate the employment relationship at any time, for any or no reason, and with or without notice.
I understand that I may be required to complete additional releases of information and provide additional information prior to consideration for employment. I further understand that submission of an application and any accompanying documents does not guarantee employment. I understand that no supervisor, manager or other representative of the agency has any authority to enter into any express or implied contract for employment for any specific period of time.
Any agreement contrary to the above must be in writing and expressly state that it is a contract and be signed by the President/CEO and/or Board Chair.
If employed, I agree to conform to the rules, regulations, policies and procedures of St. Stephen's Community House at all times and understand that such obedience is a condition of employment. I understand that due to the nature of the business, attendance is considered an essential requirement of every job and that poor attendance will result in disciplinary action. I further understand the agency's rules and regulations may be changed, interpreted, withdrawn or added to by St. Stephen's Community House at its sole option, at any time, and without prior notice to me.
IF YOU HAVE ANY QUESTIONS ABOUT ANY OF THE ABOVE STATEMENTS, PLEASE ASK THEM OF THE INTERVIEWER
BEFORE SIGNING
BY SIGNING BELOW I ACKNOWLEDGE THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ABOVE STATEMENTS
Signature of the Applicant
Date
This application will remain active for 30 days to be considered for this or similar positions. Applicants who wish to be considered after that must reapply.
Revised 1/28/2014