An Equal Opportunity Employer PLEASE COMPLETE ALL QUESTIONS ON THE APPLICATION FORM

This section is intended to give the Employer information about the education and training that the applicant has completed, and to demonstrate the skills, knowledge, and abilities of the applicant to perform the job duties of the position.

In this section, list all employment history and work experience in date order, including military experience. Begin with your current employer. Use additional paper if necessary. Failure to include all employment may be grounds for dis-qualification.

As a part of the application process, the Wayne County Children Services Board conducts background checks on all candidates for employment prior to a final offer of employment. As a result, if through the hiring process you are considered a candidate for a position with the Wayne County Children Services Board you will be subject to a background check before a final offer of em-ployment may be extended. Further, pursuant to Ohio Revised Code Section 5153.11, Criminal Records Check, the Children Services Board is prohibited from employing a person responsible for the care, custody, or control of a child if the applicant has been previously convicted or plead guilty to a violation of any of the following statutes: Section 2903.01, 2903.02, 2903.03, 2903.04, 2903.11, 2903.12, 2903.13, 2903.16, 2903.21, 2903.34, 2905.01, 2905.02, 2905.05, 2907.02, 2907.03,2907.04, 2907.05, 2907.06, 2907.07, 2907.08, 2907.09, 2907.21, 2907.22, 2907.23, 2907.25, 2907.31, 2907.32, 2907.321, 2907.322, 2907.323, 2909.02, 2909.03, 2911.01, 2911.02, 2911.11, 2911.12, 2919.12, 2919.22, 2919.24, 2919.25, 2923.12, 2923.13, 2923.161, 2925.02, 2925.03, 2925.04, 2925.05, 2925.06, or 3716.11 of the Revised Code, a violation of section 2905.04 of the Revised Code as it existed prior to July 1, 1996, a violation of section 2919.23 of the Revised Code that would have been a vio-lation of section 2905.04 of the Revised Code as it existed prior to July 1, 1996, had the violation occurred prior to that date, a violation of section 2925.11 of the Revised Code that is not a minor drug possession offense, or felonious sexual penetration in violation of former section 2907.12 of the Revised Code; or a violation of a former Ohio statute which is substantially equivalent to those violations listed above; or a violation of United States law that is substantially equivalent to those violations listed above.

I certify that all information contained in this application is true, complete and correct to the best of my knowledge, and I understand that any material omission, misrepresentation or falsification of this information is grounds for dismissal from, or refusal of, employment. I hereby authorize investigation of all statements contained in this application and give permission to contact all or any of my previous employers, references, and/or schools for information, and hold harmless all persons giving information regarding this application. I also give my consent to contact the State Motor Vehicle Department for a Moving Vehicle Violation Report.

I hereby authorize the Wayne County Children Services Board to investigate any statements or information provided in this application and to investigate my background. I agree that if, in the opinion of the Wayne County Children Services Board, I have made any misrepresentation, or the results of the investigation are not satisfactory for any reason, any offer of employment may be terminated without liability in accordance with current Wayne County Children Services Board policies or practices related thereto. I hereby authorize any person, educational institution, company or corporation to give any pertinent information as re-quested by the Wayne County Children Services Board. I understand and accept that if I am selected for employment, my employment may be conditioned upon my passing drug, alcohol or substance abuse testing. I understand and accept that the Wayne County Children Services Board will run a background check be-fore an offer of employment can be made. I hereby authorize the Wayne County Children Services Board to perform whatever background checks are required. I also agree to provide whatever information is needed to perform the background checks. By subscribing my signature to this statement, I hereby authorize any city, county, state or federal law enforcement agency or court related thereto to release to said Wayne County Children Services Board any information they possess concerning me and any prior arrests which resulted in conviction or any pending matter which has not been fully adjudicated. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Employer. This Application for Employment shall be considered active for one year. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.

Applicants are requested to complete this form, which will be used for statistical purposes only. A decision to not provide the requested information will have no affect on an applicant’s chances for employment with WCCSB. This information will be maintained separate from the application for employment. This information is not used or considered in any hiring decisions. Wayne County Children Services Board is an Equal Opportunity Employer.