Careers | Acclaim Community Care LLC

Name:

Application for Position Of

Today’s Date

Date Available

What shift are you available to work

Other - Please Explain

Present Address – Number, Street, City, State & Zip Code:

Phone Number – Include Area Code

Mailing Address – If Different from Above

Email:

Provide any different names you have utilized since age 18.

Do you have a reliable source of transportation to and from work?

Yes

No

Do you have a valid drivers license? (applicable only for certain positions)

Yes

No

Are you at least 18 years of age?

Yes

No

Are you legally eligible to work in the united states?

Yes

No

Have you live in ohio in the last 5 years?

Yes

No

Highest grade or year completed in school

Do you have a high school diploma or a ged equivalency?

Yes

No

Name and Location of High School

School Name & Location

Number of Years Attended

Credits Earned

Major Field

GPA / Basis

Degree Earned

DESCRIBE ANY OTHER EDUCATION OR TRAINING WHICH YOU FEEL IS RELEVANT TO THE JOB(S) FOR WHICH YOU ARE APPLYING. ALSO INCLUDE RELEVANT LICENSES & CERTIFICATIONS. BE SPECIFIC.

The essential functions of most jobs at Acclaim Community Care, LLC will require that employees can lift up to 50 lbs. frequently, bend and stoop frequently, stand and/or walk long periods of time, provide personal care task as needed. To the extent these functions may be applicable to the position for which you are applying, can you perform all of the above functions or perform all of the above functions with reasonable accommodation?

Yes

No

Answering “NO” to this inquiry is not an automatic bar to employment. Acclaim Community Care, LLC is an equal opportunity employer and complies with all facets of the American with Disabilities Act (and any applicable state laws). Do you have any pending criminal charges against you?

Yes

No

Have you ever been convicted of a crime, regardless of whether it was a felony or misdemeanor?

Yes

No

If you answered yes to either criminal background inquiries above, provide the date and county of the pending charge or conviction, the type of charge or conviction, and an explanation. (A pending charge or prior conviction will not automatically bar you from employment.)

Employer

Type Of Business

Job Title

Reason For Leaving

Name of Supervisor

Job Duties

Location (Street Address, City, State, Zip Code)

From (Month & Year)

To (Month & Year)

Beginning Pay $

End Pay

Employer

Type Of Business

Job Title

Reason For Leaving

Name of Supervisor

Job Duties

Location (Street Address, City, State, Zip Code)

Length of Employment

From (Month & Year)

To (Month & Year)

Beginning Pay $

End Pay

Employer

Type Of Business

Job Title

Reason For Leaving

Name of Supervisor

Job Duties

From (Month & Year)

To (Month & Year)

Beginning Pay $

End Pay

May we communicate with your present employer?

Yes

No

Former Employer?

Yes

No

Have you worked for acclaim before?

Yes

No

Which Location?

What Years?

Have you ever done any volunteer work?

If Yes, Describe:

Name

Address

Phone

Name

Address

Phone

Name

Address

Phone

BY MY SIGNATURE BELOW, I CERTIFY THAT ALL ANSWERS GIVEN BY ME ARE TRUE, ACCURATE AND COMPLETE. I UNDERSTAND THAT THE FALSIFICATION, MISREPRESENTATION OR OMISSION OF FACTS ON THIS APPLICATION (OR ANY OTHER ACCOMPANYING OR REQUIRED DOCUMENTS) WILL BE CAUSE FOR DENIAL OF EMPLOYMENT OR IMMEDIATE TERMINATION OF EMPLOYMENT, REGARDLESS OF WHEN OR HOW DISCOVERED. This application will be given every consideration, but its receipt does not imply that the applicant will be employed. It is the policy of Acclaim Community Care, LLC to afford equal opportunity to all employees and applicants for employment without regard to age, race, religion, color, sex, national origin, marital status, sexual orientation, or pregnancy, and to afford equal opportunities to disabled veterans, individuals with a disability, and any and other characteristic protected by federal, state or local law. I authorize the investigation of all statements and information contained in this application including but not limited to background checks (BCI/FBI),driving history, and references. I release from all liability anyone supplying such information and I also release Acclaim Community Care, LLC from all liability that might result from making an investigation. I acknowledge that I have read and understand the above statements and hereby grant permission to confirm the information supplied on this application by me. Date

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