Employment Application



  • Basic Information:


  • First Name:
     Last Name:

  • Phone:
    Contact Preference:
    E-mail:

  • Address:
    City:
    County:
    State:
    ZIP:

  • Will Accept:






  • Date Available To Start:

  • Positions Applying For:


  • 1):

  • 2):

  • 3):

  • 4):

  • Education:


  • High School

  • School Name:

  • Address:
    City:
    County:
    State:
    ZIP:

  • Years Completed:





  • Did you graduate?:



  • College/Trade School

  • School Name:

  • Address:
    City:
    County:
    State:
    ZIP:

  • Years Completed:





  • Did you graduate?:



  • Course of study:

  • Additional Education/Certifications:

  • Employment:


  • 1)

  • First Name:
     Last Name:

  • Phone:
    Contact Preference:
    E-mail:

  • Address:
    City:
    County:
    State:
    ZIP:

  • Employment Start Date:
    Employment End Date:

  • Salary:

  • Position:

  • Reason for Leaving:

  • Name of Supervisor:

  • 2)

  • First Name:
     Last Name:

  • Phone:
    Contact Preference:
    E-mail:

  • Address:
    City:
    County:
    State:
    ZIP:

  • Employment Start Date:
    Employment End Date:

  • Salary:

  • Position:

  • Reason for Leaving:

  • Name of Supervisor:

  • 3)

  • First Name:
     Last Name:

  • Phone:
    Contact Preference:
    E-mail:

  • Address:
    City:
    County:
    State:
    ZIP:

  • Employment Start Date:
    Employment End Date:

  • Salary:

  • Position:

  • Reason for leaving:

  • Name of Supervisor:

  • Have you been employed by OHHS before?:



  • Personal/Medical Information:


  • Have you ever been convicted of a felony or misdemeanor?:



  • Do you have any physical or mental limitations which could affect your ability to perform the job for which you have applied?:



  • References:


  • List three people, not relatives or previous supervisors. Please include full address and phone numbers.

  • 1)

  • First Name:
     Last Name:

  • Phone Number:

  • Address:
    City:
    County:
    State:
    ZIP:

  • Occupation:

  • How long has this person known you?:





  • 2)

  • First Name:
     Last Name:

  • Phone Number:

  • Address:
    City:
    County:
    State:
    ZIP:

  • Occupation:

  • How long has this person known you?:





  • 3)

  • First Name:
     Last Name:

  • Phone number:

  • Address:
    City:
    County:
    State:
    ZIP:

  • Occupation:

  • How long has this person known you?:





  • This space is provided for you to state additional qualifications and experience that you feel well-suited for the position(s) for which you have applied.

  • Additional Notes:

  • Digital Signature:


  • I certify that the above information is correct to the best of my knowledge and I understand that it is my responsibility to report any changes to the administration, if hired. I give Ohio Hills Health Services full investigative power as to my character, including criminal records, credit and financial status, or any other information deemed necessary for my application.

  • By entering your full name here, you are agreeing to the disclaimer above:

Enter This Verification Number *



* = Required