Wynn-Reeth - Online Employment Application Name  SS #  Address  City   State   Zip  Phone Position Desired  Shift(s) Desired  Have you lived in Ohio continuously for the past 5 years?  YesNo Do you have any training for the position(s) for which you are applying?  Are you related to anyone in our employ?  YesNo  If yes, who?  Can you physically and/or mentally perform the essential functions of the job for which you are applying?  YesNo Do you need reasonable accommodation to be able to perform the job function?  Do you hold any professional licenses or certifications? If so, please list:  Have you ever applied for a position with this agency in the past?  YesNo EDUCATION Name/Location Did you graduate? What degree? Attended from: to: YesNo YesNo YesNo YesNo PAST EMPLOYMENT Name/Address Title Begin date End date Wage Reason for Leaving If employed, in case of emergency, please notify: Name Relationship to you Address Telephone Number Wynn-Reeth, Inc. is an equal opportunity employer and shall not take any action regarding employment that is discriminatory on the basis of race, color, national origin, religion, sex, age or handicap. Wynn-Reeth, Inc. shall also make reasonable accommodation according to ADA Guidelines for those who qualify. By affixing my signature below, I understand that I will have to successfully pass a physical examination, TB testing, and random drug testing after the offer to hire. I also agree that if employed, I will serve to the best of my ability and will abide by the policies established by the Board of Directors. I understand that Wynn-Reeth, Inc. operates as an "employment at will" company. I authorize the former employers/individuals listed above to release all information concerning my prior employment. I also authorize Wynn-Reeth, Inc. to conduct a criminal background check and an FBI check, if applicable, and understand that my employment may be terminated if I have been convicted of a prohibited crime unless I meet personal character standards set by the Director of the Department of Health or ODMR/DD as an exception five years in the sta te of Ohio. By affixing my signature below, this shall be considered an affidavit that I have answered the residency question and all other questions on this application correctly. Further, I hold the parties and to the prohibition on employment. I understand that an FBI check is required unless I have lived the prior 5 years in Ohio. I further hold Wynn-Reeth, Inc. harmless from any consequences arising from such release. This signature also guarantees that I have not been convicted of or pleaded guilty to any of the offenses as listed on the reverse side of this application and that I will notify the employer within 14 days if I should be formally charged with, convicted of or plead guilty to any of the disqualifying events. I will also give notice within 14 days in the event that my driver’s license is revoked or suspended. PROFESSIONAL REFERENCES (PLEASE PROVIDE 2) Name/Title Company Contact Information COMMUNITY REFERENCES (PLEASE PROVIDE AT LEAST 1) Name How does this person know you? Contact Information Please note that this agency is not permitted to employ any person that has been convicted of or pleaded guilty to any of the following: 2903.01 Aggravated Murder 2907.32 Pandering Obscenity 2903.02 Murder 2907.321 Pandering Obscenity Involving a Minor 2903.03 Voluntary Manslaughter 2907.322 Pandering Sexually Oriented Matter.. 2903.04 Involuntary Manslaughter 2907.323 Illegal Use of Minor in Nudity-Oriented Material 2903.11 Felonious Assault 2911.01 Aggravated Robbery 2903.12 Aggravated Assault 2911.02 Robbery 2903.13 Assault 2911.11 Aggravated Burglary 2903.16 Failing to provide for Functionally Impaired Person 2911.12 Burglary 2903.21 Aggravated Menacing 2919.12 Unlawful Abortion 2903.34 Patient Abuse and Neglect 2919.22 Endangering Children 2905.01 Kidnapping 2919.24 Contributing to Unruliness or delinquency of ... 2905.02 Abduction 2919.25 Domestic Violence 2905.05 Criminal Child Enticement 2923.12 Carrying Concealed Weapon 2907.02 Rape 2923.13 Having Weapons While Under Disability 2907.03 Sexual Battery 2923.161 Improperly Discharging Firearm ... 2907.04 Unlawful Sexual Conduct w/a Minor 2925.02 Corrupting Another with Drugs 2907.05 Gross Sexual Imposition 2925.03 Trafficking in Drugs 2907.06 Sexual Imposition 2925.04 Illegal Manufacture of Drugs or Cultivation ... 2907.07 Importuning 2925.05 Funding of Drug Trafficking 2907.08 Voyeurism 2925.06 Illegal Administration or Distribution of Steroids 2907.09 Public Indecency 3716.11 Placing Harmful Objects in Food or Confection 2907.21 Compelling Prostitution 2905.04 Child Stealing 2907.22 Promoting Prostitution 2919.23 Interference with Custody 2907.23 Procuring 2925.11 Possession of Drugs 2907.25 Prostitution 2907.12 Felonious Sexual Penetration 2907.31 Disseminating Matter Harmful to Juveniles 5123.28 Patient Endangerment