careerapplication

Please complete all sections of the application. You may attach additional information or a resume'. Please exclude any references to your age, date of birth, race, color, sex, national origin, ancestry, disability, military status and political or religious affiliations. Your signature on the last page is required. Applicants under 18 must provide a copy of their work permit. Applicants for direct-care positions must be 18 years of age or older.

Date of Application:(mm/dd/yy)

PERSONAL INFORMATION

Name: SS#:

Last First MI

Address:

Street City State Zip

Phone: / E-mail:

Home Other

Position desired: Full-Time Part-Time

Days/Hours Available: Previously employed by FOC?

Are you authorized to work in the U.S.? How did you hear about FOC?

List any friends or relatives working for FOC:

Do you know of any reason why you cannot perform the essential functions of the job for which you are applying, with or without reasonable accommodations? Describe any accommodation(s) required:

EDUCATION

Name/Location #Years Did you Subjects - Degree GPA

Attended graduate? Major Certificate

High School:

College:

Additional College

or Graduate School:

Technical School:

Additional education, training, skills, certificates or licenses that may apply to the position of interest:

Have you lived in The State of Ohio for the past 5 consecutive years? If no, list CITY, STATE and PERIOD OF RESIDENCE for all

Residence’s over the past 5 years:

EMPLOYMENT HISTORY

Beginning with the most recent, list all employers for the past 10 years. Do not leave out any employers. Include relevant volunteer experience. Attach additional information if necessary. A resume' cannot be substituted for a completed application.

Employer: From:(mo/yr) To:(mo/yr) Title: Type of Business:

Company: Address:

City: State: Zip: Starting rate of pay: Ending rate of pay:

Supervisor/Title: Phone:

May we contact: Reason for leaving:

Job duties:

Employer: From:(mo/yr) To:(mo/yr) Title: Type of Business:

Company: Address:

City: State: Zip: Starting rate of pay: Ending rate of pay:

Supervisor/Title: Phone:

May we contact: Reason for leaving:

Job duties:

Employer: From:(mo/yr) To:(mo/yr) Title: Type of Business:

Company: Address:

City: State: Zip: Starting rate of pay: Ending rate of pay

Supervisor/Title: Phone:

May we contact: Reason for leaving:

Job duties:

REFERENCES

Please provide 3 business references and 1 family member.

Name Address Phone Years Known Business or Personal

SUPPLEMENTAL INFORMATION- Unless instructed otherwise, please provide the following information.

1. Do you have a valid driver's license? State/Number:

2. List auto accidents and moving violations from the past 3 years:

Date Location Description

3. Do you have your own means of transportation?

4. Do you have car insurance that meets Ohio's minimum standards?

5. Have you ever been convicted of a misdemeanor or felony, other tha a minor traffic offense? (NOTE: A "YES" answer will not automatically

disqualify you as a candidate for employment. (However, failure to disclose an offense may lead to automatic disqualification

from consideration).

If yes, please explain:

PLEASE READ THIS STATEMENT CAREFULLY BEFORE SIGNING

I hereby certify that all of your responses on this application, as well as all information provided in any accompanying resume' or other attachment

are complete and true. I submit that I have not knowingly withheld any facts or circumstances requested in this application and agree that any statement found to be false or misleading is reasonable cause for termination.

I further agree that any employment offered as a result of this application, if accepted by me, is "at will" and for an unspecified length of time,

and may be terminated at any time, for any reason not prohibited by law, with or without notice and with or without cause, either by me or by

this company.

This company is an equal opportunity employer, and will consider your application without regard to race, color, sex, national origin, ancestry,

religion, age, disability military status.

This application is current for (60) sixty days. At the conclusion of this time, if I have not heard from FOC and still wish to be considered for

employment, it will be necessary for me to fill out a new application.

I authorize FOC the right to contact and obtain information from all references, former employers, educational institutions and others provided

on this application and release FOC and all other persons, corporations and organizations that furnish such information from liability for

seeking, gathering and using this information.

I understand that if I am hired, I will be required to provide proof of identity and legal work authorization.

Signature: Date:

AUTHORIZATION FOR RELEASE AND USE OF CONSUMER REPORTS

OHIO LAW REQUIRED THE COMPANY TO TAKE YOUR FINGERPRINTS SO THAT THE OHIO BUREAU OF CRIMINAL IDENTIFICATION

AND INVESTIGATION CAN PERFOM A CRIMINAL RECORDS CHECK.

In addition to the criminal records check I understand that as part of the Company's procedure for processing employment applications

and for other employment purposes, including promotion, transfer or retention during the term of my employment, the company may

obtain a motor vehicle records check and/or other consumer reports. The Company typically only requests consumer reports which provide

information regarding criminal records and motor vehicle records, however, it may also request a consumer report that includes information

regarding your credit, character, general reputation, personal characteristics, and mode of living.

I understand that a Consumer Reporting Agency may not give out information about me without my written consent. I understand that no

report containing medical information about me will be provided to the Company without my specific prior consent releasing such

information, which is in addition to my general authorization, below.

I hereby authorize and request that any present or former employer, school, police department, financial institution or other person having

information or knowledge about me, furnish such information to the bearer of this authorization in connection with an application for employment.

I agree to release and discharge the company, its employees, officers, agents, affiliates and shareholders, from any and all claims, rights

of actions or liability of any kind or nature that could result from The Company's use of or reliance upon the information contained in such

consumer report(s):

Date:

Name (please print):

Signature: