Please fill out this application and mail to:
Clermont County Humane Society
4025 Filager Road
Batavia, Ohio 45103
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Name_____________________________________________
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Address___________________________________________
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State, City and Zip Code__________________________
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County_____________ Phone_____________ SS Number_____________
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Have you ever worked for us before?______
If yes, give dates______
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Have you filled out an application with us before?_______
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Are you 16 years or older?_____
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If under 18, can you provide proof of your eligibility to work?______
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Do you have any physical, mental, or medical impairment that will interfere with your ability to perform the job in which you are applying?_____________
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If yes, please explain_______________________________
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No qualified handicapped person shall on the basis of handicap, be subject to discrimination in employment.
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EMPLOYMENT DESIRED
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Position applying for__________________________
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Other Position considered________________________
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Do you need: Full time________ Part time________
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Would you consider part time if full time was not available at this time?____________
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Date available__________Expected Salary________
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Days and hours available to work____________________
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How did you hear about us?_______________________
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Do you have any relatives who work here?______________
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If yes, please give name_____________________
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If offered a job, how long do you expect to work here?_______________
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Why did you apply for this position?_________________________
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what are your feelings on euthanasia? (humane destruction of animals)_________________________________________
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Do you feel that if properly trained you could perform euthanasia?______________________
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which aspects of the job do you think you would enjoy most? Be specific___________________________________
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Do you currently own any animals?_______ If so, how many?________
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BEHAVIORAL ISSUES
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Give the amount of time you missed from work or school during the past year, for any reason, excluding FMLA leaves.___________
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Have you ever been counseled or disciplined for:
- Attendance____
- Attitude____
- Tardiness____
- Behavior____
- Customer Service____
- Performance____
- Relations with co-workers____
- Relations with supervisors____
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Have you ever been convicted (including pleadings of "no contest") of any crime (felony or misdemeanor) including traffic violations? _____ If yes, name the crime, date, place and give details_________________________________________
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EMPLOYMENT HISTORY
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Present or most recent employment_____________________
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Employer's name, address and phone number______________________________________________
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Length of employment from month____ year_____ TO month______ year______
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Reason for leaving_________________________
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Position_______________ Salary: beginning___________ end_____________
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Duties performed______________________________
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Next most recent job____________________________________
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Employers name, address and phone number______________________________________
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Length of employment from : month____ year____ TO: month_____ year______
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Reason for leaving___________________________________
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Position___________________________
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Salary: beginning__________ end____________
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Duties performed________________________________________
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EDUCATION
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Name and location of school attended_____________________________
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Other______________________________
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Please circle the last year of education completed: 1 2 3 4 5 6 7 8 9 10 11 12
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Years completed in college: 1 2 3 4
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Technical School: 1 2 3 4
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PERSONAL REFERENCE
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Please list any names, addresses and phone numbers of three references not related to you
_____________________________________
_____________________________________
_____________________________________
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SKILLS AND OTHER QUALIFICATIONS
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List professional, trade, business, school of civic associations and any offices held. (exclude memberships which would reveal sex, race, religion, national origin, age, color, disability or other protected status)___________________________________
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List certificates of licenses held or received, special accomplishments, publications, awards (exclude memberships which would reveal sex, race, religion, national origin, age, color, disability or other protected status)______________________________________
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If driving will be required in the position(s) you are applying for, please list: Driver's License Number________________
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State of Issuance____________ Type____________ Expiration date_______________
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Other skills or qualifications_________________________________
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List any other additional information you would like for us to consider_____________________________
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EMPLOYMENT ELIGIBILITY
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Are you eligible to work in the US?________ If hired you will be required to furnish documentation of your eligibility - some commonly used documents are listed below. You may ask the Recruiter for other acceptable documents.
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- Social Security Card
- US Birth Certificate
- Driver's License
- State ID card
- Current US Passport
- Certificate of Citizenship
- Current Foreign Passport with a valid work visa
- Green card with photo
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APPLICATION CERTIFICATION AUTHORIZATION AND RELEASE
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I certify that the information contained in the application and during employment interview(s) is true and complete; any falsification, misrepresentation, or material omission is grounds for refusal to hire or, for dismissal if already hired.
I authorize my previous employers, educational institutions, and other references to release any information to the Clermont County Humane Society. Or any of its subsidiaries that may assist in making an employment decision. I authorize CCHS to request and receive such information. I understand that any such reference information will not be disclosed to me.
I specifically authorize CCHS to contact any law enforcement agency and authorize such law enforcement agency to furnish any information about me that may be sought by CCHS unless expressly prohibited by federal or state law.
I hereby release from liability CCHS and its representatives for seeking information in connection with my application for employment and all other persons, corporation or organizations for furnishing such information. I hereby release the Company and any person, organization or prior employer from any obligation to provide me with written notification of such disclosure, except as required by law.
All offers of employment are contingent upon satisfactory results of police check and drug or alcohol test results and references.
All employment which may be offered is voluntarily entered with mutual rights to termination and is not guaranteed for any term.
A photostatic copy of this authorization and release may be accepted in lieu of the original. If I am not hired within 30 days, this application is no longer active and I will need to reapply for employment if I wish to be considered for a job at CCHS.
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Signature______________________________ Date________________
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