1. education
2. graduate school
3. college

HOCKING COUNTY BOARD OF DEVELOPMENTAL DISABILITIES
1369 E. FRONT STREET P.O. BOX 387 LOGAN, OHIO 43138
740-385-6805
EMPLOYMENT APPLICATION
Name ________________________________________________Date ________________
Last
First
Middle
TO ALL APPLICANTS – (Please read carefully)
Thank you for your interest in employment with the Board. The Board provides a broad range of service
to children and adults with mental retardation and developmental disabilities who live in the county.
When completing your application, please provide as much detail as possible and answer all questions
thoroughly. Type or print clearly. If you need assistance completing the application, please advise the
Personnel Department. Be sure your signature and the date appear on the last page of the application and
return the completed application to the Personnel Department at the above address. All applications will
be kept on active status for a period of two years. If you are not hired but continue to have an interest in
employment after this period of time, you will need to complete a new application.
HIRING PROCESS
When completed applications are received by the Personnel Department, they are reviewed and made
available to the supervisors in the facilities where appropriate openings exist based upon the applicant’s
stated areas of interest and qualifications.
Because there are generally more applicants than available positions, not all applicants will receive
interviews. Interviews are scheduled by the supervisor in the facility/department based upon the
applicant’s qualifications and ability to perform the essential job functions of the position with or without
reasonable accommodation. Following the initial interview, applicants may be recommended for
additional interviews with other staff, supervisors and the Superintendent. All offers of employment may
be extended only by the Superintendent. All offers of employment are contingent upon successful
completion of a job-related medical examination, a criminal history background check, and if the position
requires the person to transport clients or operate agency vehicles for any other purpose, a driving
abstract.
CERTIFICATION / LICENSURE / REGISTRATION
Some positions require certification, licensure and/or registration. If you are applying for any of these
positions, complete the appropriate information on the application and enclose a copy of the certificate,
license and/or registration. If you are hired, you will need to bring the original certificate / license and/or
registration in for review and copying. Applicants who have completed college or coursework related to
the position applied for are requested to submit official transcripts with the application. If hired, official
transcripts must be submitted prior to any salary credit for education.
*************************************************************************************
THE BOARD IS AN EQUAL OPPORTUNITY EMPLOYER
This philosophy calls for equal opportunity for employment, training and advancement regardless of sex,
race, creed, color, age, national origin, religion, physical or mental disability or any other factors
unrelated to the essential duties of the position.
PERSONAL INFORMATION
(Please type or print clearly)
Name ________________________________________ ____________SSN _______________________
Last
First
Middle
Address _____________________________________________________________________________
No.
Street
City
State
Zip
Telephone (___)_______________
Position(s) applied for
1. ___________________________ Expected pay rate $_____per _____
2. ___________________________ Expected pay rate $_____per _____
Location preferred, if any _____________________________
Date available to start work ____________________________
How did you learn of this opening? ____________________________
Have you ever worked for this agency before? Yes / No
Do you have friends or relatives working for this agency? Yes / No
(It is Board policy not to place an employee under the supervision of a friend or relative)
EMPLOYMENT HISTORY – List most recent first. Use additional sheet if necessary. If your job title
or duties changed during employment with any one employer, please list as separate employers. A
resume may not be used as a substitute for completing this application.
Name of Employer_____________________________________________ Telephone (___) _________
Address ______________________________________________________________________________
Name & Title of Supervisor ______________________________________________________________
Job Title ____________________________ Dates of employment ______to_____ ending salary _______
Describe responsibilities ________________________________________________________________
Reason for leaving _____________________________________________________________________
Name of Employer____________________________________________ Telephone (___) __________
Address ______________________________________________________________________________
Name & Title of Supervisor ______________________________________________________________
Job Title ____________________________ Dates of employment ______to_____ ending salary _______
Describe responsibilities ________________________________________________________________
Reason for leaving _____________________________________________________________________
Name of Employer____________________________________________ Telephone (___) __________
Address ______________________________________________________________________________
Name & Title of Supervisor ______________________________________________________________
Job Title ____________________________ Dates of employment ______to_____ ending salary _______
Describe responsibilities ________________________________________________________________
Reason for leaving _____________________________________________________________________
List the employees we may NOT contact for a reference _______________________________________
EDUCATION
Type
Complete Name & Address
High School
College
Post Graduate*
Business or Trade*
Other
Years
Graduated
Complet Yes or No
ed
(circle)
1234
1234
1234
1234
1234
Degree
Major
*Please submit transcripts (copies accepted for applications – official transcripts required upon hire)
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.
Certification for the Ohio Department of Education
_____________________________________________________________________________________
Type
Grade
Expiration Date
Certification or registration from the Ohio Department of DD
_____________________________________________________________________________________
Type
Grade
Expiration Date
Please list other certificates, registrations or licenses you have that are required for the position(s) for
which you applied.
Type of Certificate/Registration/License
Authorizing Board or Agency
Expiration
Date
1.
2.
3.
MISCELLANEOUS
1. Have you ever been discharged for requested to resign from a position? Yes / No If yes, explain
_____________________________________________________________________________________
2. Have you ever had a certificate, license or registration revoked or suspended? Yes / No If yes, explain
_____________________________________________________________________________________
3. Can you perform the essential functions of the specific job(s) for which you are applying as listed in
the Position Description? Yes / No If no, please list which essential function(s) you would have
difficulty performing and identify possible reasonable accommodations.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
NOTICE OF REQUIREMENT FO CRIMINAL HISTORY BACKGROUND CHECK
The Board 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 hire 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. This is not subject to the Ohio
Public Record Act.
Have you ever been convicted of a felony? Yes / No
If yes please explain ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
You will be given a copy of this report. I agree that, if at any time after I am hired and charged with a
listed offense, I must inform the Superintendent. Failure to inform the Superintendent may result in
termination.
____________________________________________
Signature
Date
REFERENCES
List three (3) references, excluding former employers and relatives that this agency has permission to
contact, you must include phone numbers.
1. ___________________________________________________________
2. ___________________________________________________________
3. ___________________________________________________________
ADDITIONAL INFORMATION
Please summarize other experiences, skills, or qualifications which you feel would qualify you for the
position(s) for which you have applied.
APPLICANT’S AGREEMENT
I certify that I have read and understand the instructions on the front page and all other information on this
application and that the answers given by my 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 rejection of my applications or immediate discharge at any time during my
employment. I understand that, as a condition of initial or continued employment, I agree to submit to
such lawful examination, 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 and record sources. I authorize all employers (unless restricted on page 2 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 which I am applying. I am
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 which involve certification, registration, licensure and training. I further understand that I
may be required to enroll in college courses and/or other training at my expense.
I grant permission to have this application and enclosures duplicated and to be distributed to the Board’s
employees responsible for initial screening, interviewing, recommending applicants for employment and
to employees responsible for personnel records and reports.
_________________________________________
Signature
_________________
Date
AN EQUAL OPPORTUNITY EMPLOYER
__________________EQUAL EMPLOYMENT OPPORTUNITY_________________
The Ohio Fair Employment Practice Law prohibits employment practices that discriminate based on race,
color, religion, sex, age, national origin, qualifying disability, or ancestry. The 1964 Civil Rights Act,
Title VII, prohibits discrimination based on race, color, religion, sex, or national origin.
The Ohio Administrative Code, Section 4112-5-04, requires the Hocking County Board of Developmental
Disabilities to record and report the information listed below. Please help us comply by providing the
answers to the following questions.
This Equal Employment Opportunity Form will be kept in a CONFIDENTIAL FILE separate from the
Application for Employment. It will not be used to determine employment eligibility.
POSITION APPLIED FOR:
_____________________________________________
RACE/ETHNIC GROUP:






American Indian/Alaskan Native
Asian/Pacific Islander
Hispanic
Black
White
Other
SEX:


Female
Male
VIETNAM ERA VETERAN:


Yes
No
DISABLED VETERAN:


Yes
No
DO YOU HAVE A DISABILITY OR MEDICAL CONDITION THAT NEEDS TO BE
ACCOMMODATED TO PROVIDE YOU WITH AN ACCESSIBEL WORK ENVIRONMENT?


REFFERED BY:
 Job Posting
 Friend
Yes
No
 Newspaper: ______________________________
 Other (please specify):_____________________________
Thank you for completing this form.
THIS INFORMATION IS TO BE UTILIZED FOR AFFIRMATIVE ACTION USE ONLY.