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Employment Requirements

EMRI requires a criminal background check as a condition for employment. Are you willing to be considered for an assignment to work with individuals with DDS that require a background check? (A conviction is not an automatic elimination for employment)*

Yes

Do you have a legal right to reside and work in this country?*

Yes

Would you be willing to take a drug test as a condition for employment?*

Yes

Applicant

Application Date*

Month

Day

Year

Date of Birth*

Month

Day

Year

Last Name*

First Name*

Middle Initial

Maiden, Alias or other Name(s) you use or have used in the past

Current Address*

Street Address City State ZIP Code

Cellular Phone Number

Home Phone Number

In case of an emergency, who should EMRI notify?*

Relationship to you?

Emergency Contact Phone Number

Desired Work Schedule

What position(s) are you applying for?

Who referred you to EMRI, LLC?

Please indicate the type of work you are seeking?

Full Time

Part Time

Temporary

Please indicate your desired shift

1st (9am-3pm)

2nd (3pm-11pm)

3rd (11pm-9am)

Please indicate which days you are available to work

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Have you ever worked in the field of Developmental Disabilities?

Yes

For how long?

Salary Requirements

Hourly

Annually

Certifications & Skills

Direct Care Staff Initial Training

Yes

Expiration Date

Month

Day

Year

CPR Certified

Yes

Expiration Date

Month

Day

Year

First Aid Certified

Yes

Expiration Date

Month

Day

Year

Medication Administration

Yes

Expiration Date

Month

Day

Year

Computer Skills

(List computer skills/programs you are familiar with including basic functions)

Education

School Name

Years Attended

Month/Year Graduated

Degree / Special Subject Studied

Employment History

(Start with current or most recent)

Employer Name

Employer Address

Employer Phone Number

Supervisor's Name

Supervisor's Phone Number

May we contact for reference

Yes

Employment Dates (list both Start and Finish dates below)

Employment Salary (list both starting salary and ending salary below)

Reason for leaving

Employer Name

Employer Address

Employer Phone Number

Supervisor's Name

Supervisor's Phone Number

May we contact for reference

Yes

Employment Dates (list both Start and Finish dates below)

Employment Salary (list both starting salary and ending salary below)

Reason for leaving

Employer Name

Employer Address

Employer Phone Number

Supervisor's Name

Supervisor's Phone Number

May we contact for reference

Yes

Employment Dates (list both Start and Finish dates below)

Employment Salary (list both starting salary and ending salary below)

Reason for leaving

Document Upload

Attach relevant documents such as any resumes or educational credentials

Drop files here or

Max. file size: 100 MB.

References (please list two professionals who are familiar with your background and can evaluate your abilities)

Name

Title

Phone Number

Address (Street, City, State, Zip)

Equal Opportunity Employer

EEO Statement: EMRI provides equal employment opportunity to all employees and applicants without regard to age, race, creed, color, religion, national origin, sex, disability, veteran status or marital status. This policy governs all areas of employment at STAFFING ALTERNATIVES of Ohio, including recruiting, hiring, work assignments, promotions, compensation, discipline and termination. Additionally, EMRI does not invite or honor any discriminatory job orders or requests by clients

Employment Agreements

Confidentiality Agreement: In the event that I am hired by EMRI, except authorized by any client to which I am assigned, I will not disclose, use or take directly or indirectly, either during or after my assignment, any property of the client or confidential or proprietary information concerning the client and/or their business or personal belongings. I also agree to deliver promptly to the client (on request or on the date of termination from my assignment) all documents, copies thereof and other materials relating to any confidential or proprietary information which are the property of the client.

Agreed Upon Condition of Employment: I understand that if my employment with EMRI is termed “at-will”, meaning that either I, or EMRI, can terminate the employment relationship at any time for any lawful reason with or without notice. I acknowledge that any false, misleading or incomplete information I provide on this application form, on the resume or in pre-employment interview will be grounds to deny my application or, if discovered later, for immediate dismissal from employment.

By checking this box I certify that I have provided accurate information and that I have read and understand the Employment Agreement*

I agree

First Name*

Last Name*

Today's Date*

MM slash DD slash YYYY

Name

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