ERH - Episcopal Retirement Homes

Employment Application

PLEASE NOTE: Pressing "Enter" or "Return" to move through the fields will send your application prematurely to our employment office. Use the "Tab" key to navigate through
the fields. Thank you for your interest in Episcopal Retirement Homes.

Please make sure you have completed all fields before submitting.

Position applying for
Last name
First name
Middle initial
Address

City
State
ZIP code
E-mail address
Please subscribe me to ERH's monthly e-News.	Yes No
Primary phone (area code first)
Alternate phone (area code first)

Employment information/Availability
Other formal names by which you have worked or attended school
Have you ever worked for Episcopal Retirement Homes, including Deupree House, Marjorie P. Lee, Canterbury Court, Cambridge Heights Apartments or St.Paul Village before?	Yes No
If yes, which facility
If yes, when
Employment status desired:	Full-time Part-time PRN
Expected salary
Date available to start
Days and hours available to work (enter hours only on the days you can work)
Monday:
Tuesday:
Wednesday:
Thursday:
Friday:
Saturday:
Sunday:
How did you hear about us? (check all that apply)	Current Employee Referral Employee name Newspaper (select one) Job News Queen City Jobs Cincinnati Enquirer Job Fair CEU Event Preceptor Program Other Please specify:
Are you able to work in the US? If hired you will be required to furnish documentation of your eligibility.	Yes No
Do you have access to reliable transportation?	Yes No
Which aspect of the job do you think you would enjoy the most? Be specific.
How much time have you missed from work or school during the past year (for any reason)?
Have you ever been counseled or disciplined for: (check all that apply)	Attendance Attitude behavior Customer service skills Performance relations with co-workers Relations with supervisor Tardiness

Criminal history As a health care organization, we will do a full background check. Even expunged criminal records are accessible to us. Convictions do not necessarily prevent employment, however, failure to disclose information regarding convictions will be considered falsification of information and is grounds for refusal to hire or for dismissal if already hired.
Have you ever been convicted of any crime (felony or misdemeanor), including pleading “No Contest,” expungements, or any traffic violations, whether or not time was served?	Yes No
If yes, specify crime, date, place and give details:

Education
High school name
High school city and state
Did you graduate or receive your GED?	Yes No
Grade completed:
If GED, date received:
College or other schools attended:
Location:
Years of attendance:
Did you graduate?	Yes No
Diploma, degree or certificate:
GPA:
Course of study:
List professional, trade, business, school or civic associations and any offices held (exclude memberships which would reveal sex, race, religion, national origin, age, color, disability or other protected status)
List certificates or licenses held or received, special accomplishments, publications, awards (exclude credentials which would reveal sex, race, religion, national origin, age, color, disability or other protected status)
Ohio RN/LPN license number:
Ohio RN/LPN expiration date:
CPR certification:
CPR expiration date:
Other skills and qualifications-Summarize special skills, knowledge, and/or qualifications acquired from employment or other experiences that may qualify you to work with our company and pertain to the position for which you are applying (e.g. computer skills, typing, bed bath):

Employment History List your most recent employers, assignments, military experience, school or volunteer activities, starting with the most recent. Please explain your employment history over the last 10 years or four (4) employers, whichever is longer. Please use an employer space to explain any gaps in employment.
Current or last employer
Telephone number (area code first)
Responsibilities
Employment dates	From To
Immediate supervisor's name
Immediate supervisor's title
Immediate supervisor's phone (area code first)
Your job title
Full-time Part-time PRN Temporary/Summer
Wages and other compensation	Starting Rate Ending Rate
Reason for leaving/wanting to leave
May we contact your current employer for reference?	Yes No After accepting the offer N/A-not currently employed

Second last employer
Telephone number (area code first)
Responsibilities
Employment dates	From To
Immediate supervisor's name
Immediate supervisor's title
Immediate supervisor's phone (area code first)
Your job title
Full-time Part-time PRN Temporary/Summer
Wages and other compensation	Starting Rate Ending Rate
Reason for leaving/wanting to leave
May we contact this employer for reference?	Yes No After accepting the offer N/A-not currently employed

Third last employer
Telephone number (area code first)
Responsibilities
Employment dates	From To
Immediate supervisor's name
Immediate supervisor's title
Immediate supervisor's phone (area code first)
Your job title
Full-time Part-time PRN Temporary/Summer
Wages and other compensation	Starting Rate Ending Rate
Reason for leaving/wanting to leave
May we contact this employer for reference?	Yes No After accepting the offer N/A-not currently employed

Fourth last employer
Telephone number (area code first)
Responsibilities
Employment dates	From To
Immediate supervisor's name
Immediate supervisor's title
Immediate supervisor's phone (area code first)
Your job title
Full-time Part-time PRN Temporary/Summer
Wages and other compensation	Starting Rate Ending Rate
Reason for leaving/wanting to leave
May we contact this employer for reference?	Yes No After accepting the offer N/A-not currently employed

Have you disclosed a complete list of your employment for at least the last 10 years or four (4) employers, whichever is longer?	Yes No
If no, you need to complete an Employment History Addendum. Please contact a member of the Employment Office team.

List any additional information you would like us to consider:
Are you at least 16 years old?	Yes No
Are you at least 18 years old?	Yes No
If you are under 18, you must provide a work permit form your school before you may begin work. Your parent or guardian must also sign a permit obtained in the Employment Office.

By entering your name below you agree to the following: I certify that the information contained in this application is true and complete; any falsification, misrepresentations, or significant omission on the application 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 ERH that may assist in making an employment decision. I authorize ERH to request and receive such information. I understand that any such reference information will not be disclosed to me. I specifically authorize ERH to contact any law enforcement agency and authorize such law enforcement agency to furnish any information about me that may be sought by ERH, unless expressly prohibited by federal, state or local law. I hereby release from liability ERH and its representatives for seeking information in connection with my application for employment and all other persons, corporations or organizations for furnishing such information. I hereby release ERH 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 criminal history check, fingerprinting and drug and/or alcohol test results, references, medical questionnaire and physical examination. Any employment which ERH may offer to me is entered into voluntarily with mutual rights for termination and is not guaranteed for any length of time. A photostatic copy of this certification, authorization and release may be accepted in lieu of the original. If I am not contacted by ERH within three (3) months, this application is no longer considered active and I will need to reapply for employment if I wish to be considered for another job at ERH.
Type your name here:
Thank you for taking the time to complete this application.

Episcopal Retirement Homes, Inc.
3870 Virginia Ave.
Cincinnati, OH 45227
Ph: (513) 271-9610
Fax: (513) 271-9648

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