North East Ohio Network

Transcription

1 NORTH EAST OHIO NETWORK REV 2/ MAHONING AVE. SUITE 102 AUSTINTOWN, OHIO PHONE TOLL FREE MUI & FINANCE FAX PROGRAM OPERATIONS & ADMINISTRATION FAX WEBSITE North East Ohio Network NEON is an Ohio Public Employee Retirement System (OPERS) employer serving 14 County Boards of Developmental Disabilities in Northeast Ohio Employment Application Checklist Please print, scan and submit all required items electronically to Incomplete applications will not be accepted Application Complete pages 1-4 of the application and save as a PDF Resume Cover Letter with Salary Requirements Three Professional References (Most Recent Supervisors or Managers) Transcripts or a Copy of Diploma (If Job applied for Requires a Degree)

2 APPLICATION FOR EMPLOYMENT Instructions: Fill out all requested information on this application. All sections must be completed in full even if a resume is included. Once completed, save a copy to your computer and it to the hiring manager along with all information on the Employment Application Checklist. PERSONAL NORTH EAST OHIO NETWORK 5121 MAHONING AVE. SUITE 102 AUSTINTOWN, OHIO PHONE TOLL FREE MUI & FINANCE FAX PROGRAM OPERATIONS & ADMINISTRATION FAX WEBSITE Name: Last First Middle Date Address: Street City State Zip Code + 4 Telephone: Home ( ) Are you legally authorized to work in the U.S.? Yes No Cell ( ) Have you every worked under a different name? Yes No Work ( ) If yes, what name? Social Security Number: - - Have you ever been employed by N.E.O.N.? Yes. When? Under what name? What prompted you to apply here for employment? N.E.O.N. employee (Name: ) Newspaper Ad Other (specify) No Title of Position Applied For: Full Time Temporary Date Available for Work Part Time Any Are you willing to work (check all that apply) Number of hours willing Salary Desired to work per week? Days Evenings Weekends Holidays $ per hour Do you have any immediate relatives employed at N.E.O.N.? Yes No Name Department Relationship Have you applied at N.E.O.N. within the past year? Yes No If yes, approximate date:

3 EDUCATION Major or Circle Last Did you School Name & Address of School Course of Study Year Completed Graduate? List Diploma or Degree High Yes No College Yes No College Yes No OTHER, such as Business College, other Special Courses (include special military, post graduate and nursing training) LICENSURE Professional Licenses and/or Certifications Are you currently Registered Licensed Certified Are you eligible but pending any of the above? Please explain: IF LICENSED, REGISTERED, OR CERTIFIED Has your professional license ever been suspended or revoked? Yes No If yes, explain: SKILLS This section is only for Office Support Applicants Typing Skills: Yes No Speed wpm Office Machine & other Applicable Knowledge/Training Dictaphone: Yes No Transcription: Yes No Computer Skills: Medical Terminology: Yes No Spreadsheet Management: Yes No Data Base Management: Yes No Background Investigation: Pursuant to Ohio Administrative Code Section 5123:2-2-02, the Northeast Ohio Network (NEON) Council of Governments is required to conduct background investigations for purposes of employment. Please note that per 5123:2-2-02, there are five tiers of disqualifying offenses with corresponding time periods that preclude an applicant from being employed with this agency. Therefore, all applicants under final consideration will be required to submit to a background check through the Bureau of Criminal Identification and Investigation. For more information, please review OAC 5123: Your signature below verifies only that you understand our requirement to conduct background checks following job offers. Your signature also verifies that you further understand that all prospective employees must pass a drug test prior to being hired. Signature Date

4 WORK HISTORY List Name, Address, and Phone Number of Your Last 4 Employers. PLEASE LIST MOST RECENT EMPLOYER FIRST May we contact the employers listed above? Employer #1 Yes No Employer #2 Yes No Employer #3 Yes No Employer #4 Yes No

5 PLEASE READ THE FOLLOWING INFORMATION CAREFULLY An Equal Opportunity Employer In compliance with Federal and State equal employment opportunity laws, all qualified candidates will be considered for employment based on ability and qualifications, and without discrimination because of their race, creed, color, national origin, ancestry, sex, age, marital status, veteran status, sexual orientation, or physical and mental disabilities. Statement of Applicant s Certification and Agreement The distribution or receiving of this application by the Company does not imply or intend to imply an agreement or contract to employ the applicant. The purpose of this application is solely to allow persons a standardized form on which to submit their qualifications. This application will be considered valid for no longer than three months. Re-application is necessary after three months. I understand references and work history verification is required, and I authorize all persons, schools, employers, and organizations mentioned in this application to provide the Company with any and all information requested by the Company, and I voluntarily release such persons, schools, employers, and organizations from all liability for providing such information. In the event that I am employed by the Company, I agree to comply with all its rules, regulations, and directions. I understand that my employment is for no stated term. In the event that I am employed by the Company, I agree to provide prior to hire all designated prerequisite items (e.g. proving my identity and my eligibility to work in the United States, successful completion and satisfactory results from physical examination, criminal background check, motor vehicle record check, licensure/certification and academic verification, CPR, and medical information such as immunization, TB, MMR, HepB, etc.). I understand failure to provide such items will cause me to be ineligible for employment. In the event that I am employed by the Company, I authorize the Company to obtain my driving record periodically after employment so that the Company can maintain compliance with federal contracting requirements. In the event that I am employed by the Company, and I am photographed during the course of my employment, I grant the Company my permission to use any or all photos of me for various public relations releases. In the event that I am employed by the Company, I understand that the Company is a drug-free working environment, and that the unlawful manufacture, distribution, dispensing, possession or use of a controlled substance is prohibited. In the event that I am employed by the Company, I understand that the Company is a smoke-free working environment, and agree to abide by rules regarding when and where I may smoke. In the event that I am employed by the Company, I also understand that regular employee status depends upon successful completion of an adjustment period as specified by the Company. I certify that I have not been excluded from Medicare and Medicaid program participation. I certify that I am a genuine applicant for employment and this application is being submitted for the purpose of seeking employment with the Company. I certify that all statements made by me on this application are true and complete to the best of my knowledge and that I have withheld nothing that, if disclosed, would affect this application unfavorably. I understand that falsification, misrepresentation, or omission of facts called for in this application may result in denial of employment or immediate dismissal. I hereby acknowledge that I have read, understand, and consent to all statements on this page. Date Signed Applicant s Signature Please print, scan and submit all required items electronically to employment@neoncog.org. Thank you for completing this application form and for your interest in employment with us.