Employment Application

Please complete all sections of the application. You may attach additional information or a resume. Please exclude any references to your age, date of birth, race, color, sex, national origin, ancestry, disability, military status and political or religious affiliations. Applicants under 18 must provide a copy of their work permit. Applicants for direct-care positions must be 18 years of age or older.

Personal Information

First Name *

Middle Name

Last Name *

Street Address *

City *

State *

Zip *

Home Phone *

Other Phone

Email *

Region you are applying to: *

Position

Position Desired *

Status *

Days/Hours Available

Previously employed by RMS? *

Are you authorized to work in the U.S.? *

How did you hear about RMS?

Residency

Have you lived in the state of Ohio for the past 5 consecutive years?

If no, list CITY, STATE, and PERIOD OF RESIDENCE for all residences over the past 5 years.

Job Related Questions

List any friends or relatives working for RMS

Do you know of any reason why you cannot perform the essential functions of the job for which you are applying, with or without reasonable accommodations?

Describe any accommodations(s) required

Education

High School

High School Name

High School Location (City, State)

Number of years attending High School?

Did you graduate High School?

Subjects/Majors

Degree/Certificate Received

GPA

College

College Name

College Location (City, State)

Number of years attending College?

Did you graduate College?

Subjects/Majors

Degree/Certificate Received

GPA

Additional College

Additional College Name

Additional College Location (City, State)

Number of years attending Additional College?

Did you graduate Additional College?

Subjects/Majors

Degree/Certificate Received

GPA

Technical School

Technical School Name

Technical School Location (City, State)

Number of years attending Technical School?

Did you graduate Technical School?

Subjects/Majors

Degree/Certificate Received

GPA

Additional Information

Additional education, training, skils, certificates or licenses that may apply to the position of interest

Employment History

Beginning with the most recent, list all employers from the past 10 years. Do not leave out any employers. Include relevant volunteer experience. Attach additional information if necessary. A resume cannot be substituted for a completed application.

Company

Type of Business

Title

Worked from

Worked to

Reason for Leaving

Street Address

City

State

Supervisor/Title

Phone

Starting rate of pay

Ending rate of pay

May we contact?

Job Duties

Company

Type of Business

Title

Worked from

Worked to

Reason for Leaving

Street Address

City

State

Supervisor/Title

Phone

Starting rate of pay

Ending rate of pay

May we contact?

Job Duties

Company

Type of Business

Title

Worked from

Worked to

Reason for Leaving

Street Address

City

State

Supervisor/Title

Phone

Starting rate of pay

Ending rate of pay

May we contact?

Job Duties

Company

Type of Business

Title

Worked from

Worked to

Reason for Leaving

Street Address

City

State

Supervisor/Title

Phone

Starting rate of pay

Ending rate of pay

May we contact?

Job Duties

References

Please provide 3 business references and 1 family member.

Name

Address

Phone

Years Known

Type

Name

Address

Phone

Years Known

Type

Name

Address

Phone

Years Known

Type

Name

Address

Phone

Years Known

Type

Supplemental Information

1. Do you have a Valid Driver's License?

2. List all auto accidents and moving violations from the past 3 years (Date, Location, Description):

3. Do you have your own means of transportation?

4. Do you have car insurance that meets Ohio’s minimum standards?

5. Have you ever been convicted of a misdemeanor or felony, other than a minor traffic offense? (NOTE: A “YES” answer will not automatically disqualify you as a candidate for employment. However, failure to disclose an offense may lead to automatic disqualification from consideration).

If Yes, Explain:

PLEASE READ THIS STATEMENT CAREFULLY

I hereby certify that all of my responses on this application, as well as all information provided in any accompanying resume or other attachment are complete and true. I submit that I have not knowingly withheld any facts or circumstances requested in this application and agree that any statement found to be false or misleading is reasonable cause for termination.

I further agree that any employment offered as a result of this application, if accepted by me, is "at will" and for an unspecified length of time, and may be terminated at any time, for any reason not prohibited by law, with or without notice and with or without cause, either by me or by this company.

This company is an equal opportunity employer, and will consider your application without regard to race, color, sex, national origin, ancestry, religion, age, disability or military status.

This application is current for (60) sixty days. At the conclusion of this time, if I have not heard from RMS and still wish to be considered for employment, it will be necessary for me to fill out a new application

I authorize RMS the right to contact and obtain information from all references, former employers, educational institutions and others provided on this application and release RMS and all other persons, corporations and organizations that furnish such information from liability for seeking, gathering and using this information.

I understand that if I am hired, I will be required to provide proof of identity and legal work authorization.


AUTHORIZATION FOR RELEASE AND USE OF CONSUMER REPORTS

OHIO LAW REQUIRES THE COMPANY TO TAKE YOUR FINGERPRINTS SO THAT THE OHIO BUREAU OF CRIMINAL IDENTIFICATION AND INVESTIGATION CAN PERFORM A CRIMINAL RECORDS CHECK. 

In addition to the criminal records check I understand that as a part of the Company’s procedure for processing employment applications and for other employment purposes, including promotion, transfer or retention during the term of my employment, the company may obtain a motor vehicle records check and/or other consumer reports. The Company typically only requests consumer reports which provide information regarding criminal records and motor vehicle records, however, it may also request a consumer report that includes information regarding your credit, character, general reputation, personal characteristics, and mode of living.

I understand that a Consumer Reporting Agency may not give out information about me without my written consent. I understand that no report containing medical information about me will be provided to the Company without my specific prior consent releasing such information, which is in addition to my general authorization, below.

I hereby authorize the Company to request a report from the Ohio Bureau of Criminal Identification and Investigation, the Ohio Bureau of Motor Vehicles, and other Consumer Reporting Agencies to be used for employment related purposes, including hiring, promotion, transfer, or retention now or in the future.

I hereby authorize and request that any present or former employer, school, police department, financial institution or other person having information or knowledge about me, furnish such information to the bearer of this authorization in connection with an application for employment.

I agree to release and discharge the company, its employees, officers, agents, affiliates and shareholders, from any and all claims, rights of action or liability of any kind or nature that could result from the Company’s use of or reliance upon the information contained in such consumer report(s)

* I have read this Agreement and agree to the terms and conditions listed above.

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