Rose Garden Nursing Home is an Equal Opportunity Employer, committed to employing individuals without regard to race, color, age, sex, marital status, veteran status, religion, creed, national origin, ancestry, or handicap.

Date of Application ______________________
Interview Date__________________________

 Name: __________________________________   Social Security # ________________________
Phone # _____________________________________

Current Address ___________________________________________________________________________
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 dates                           street                                        city                               county  state     zip code

 dates                           street                                        city                               county  state     zip code

 dates                           street                                        city                               county  state     zip code

 dates                           street                                        city                               county  state     zip code

You will be required to supply proof of Ohio residency for the last 5 years.  Federal law upon employment requires proof of citizenship or immigration status.

Are you at least 18 years old?  Yes       No       If employed and you are under 18, can you furnish a work permit?  Yes                  No      

State law and the company mandates background checks on all employees.  If hired, you will be fingerprinted to comply with state law.  (See last page)

GENERAL:

Have you ever applied to or been employed by our Company before?  Yes        No        If yes give dates:

Are you employed now?                  If so, may we contact your present employer?  Yes      No ____

Person to contact                                                                                  Phone #    

Are you on layoff due to lack of work and subject to recall?  Yes          No ____

If employed, does your employment require you to continue working for your current employer, or restrict your activities after leaving your current employment, for any period of time?  Yes               No ___

If yes, until what date?                                           .

For what position(s) are you applying? 

Where did you hear of this position? ___________________________________________________________

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Are you a veteran of the U.S. Military service?  Yes             No       
If yes, describe:
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Have you been convicted of a crime or pled guilty or no contest to a crime, other than a minor traffic violation?  A conviction will not necessarily bar you from consideration for employment.   Yes _____No ____

If yes, describe:
____________________________________________________________________________
______________________________________________________________________________________

Date you can start:                                            Salary Desired: ____________________________

APPLICANT'S CERTIFICATION AND AGREEMENT

WHY DO I HAVE TO GET FINGERPRINTED?

When you apply for this job, you have to get fingerprinted and sign a form.  WE AREN’T DOING THIS BECAUSE WE DON’T TRUST YOU OR DON’T WANT YOU TO COME TO WORK FOR US.  WE’RE DOING IT BECAUSE WE HAVE TO UNDER STATE LAW.

A state law says people who work with the elderly have to be checked to see if they have a criminal record.  This is true even if you don’t have a record.  The law was passed to protect elderly people (and people who work with them) from convicted criminals.

The law also says you have to get fingerprinted.  This is how the state checks to see whether you have a record.  We apologize for the inconvenience and appreciate your interest in working with us!           

LONG TERM CARE WORKER BACKGROUND CHECK

OHIO REVISED CODE SECTION G

CONSENT AND ATTESTATION FORM

By signing this form, I consent to the submission of a request for criminal records check for long term care workers as required by Ohio Revised Code section G.  Rose Garden Nursing Home will submit the request.

I also attest to the following:

1. That I have not been convicted of or pleaded guilty to any of the crimes that would disqualify me from working with older adults under Ohio Revised Code section G.  (See list on back)

2. That I understand and agree that if I am found to have a record of any of those crimes, I may not be hired for work with older adults or, if I have already been hired, my employment may be terminated.

3. That I was informed that I must provide a set of fingerprint impressions and that a criminal records check must be conducted if I come under final consideration for employment.

4. That should I be charged with, convicted of, or plea guilty to any offenses listed or described in the revised code paragraph (G) (1) to (G) (4), subsequent to my employment, I shall notify the employer within 14 days of such an offense.  I also recognize that failure to report any formal charges, convictions, or guilty pleas may result in my termination with Rose Garden Nursing Home.

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Signature of Applicant                                                                                                   Date