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EMPLOYMENT APPLICATION

Click here for PDF of
Employment Application
that you can print out and mail

Thank you for your interest in employment with our company. For your convenience, there are three ways to submit your employment application - visit one of our regional offices between the hours of 10am and 2pm, Monday through Friday to complete the application in person; print and mail a PDF copy of the employment application; or complete the on-line application below. Whichever method you choose, please be sure to include all information requested on the application as incomplete applications will not be considered. If you should have questions or need any assistance please contact Samuel Hoar.

Please complete all sections of the application. You may attach additional information or a resume after submitting form. Please exclude any references to your age, date of birth, race, color, sex, sexual preference, 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. RMS abides by Ohio Workers Compensation laws, and by Chapter 3794. of the Ohio Revised Code (ORC) which prohibits all forms of tobacco smoke in all public places and places of employment and in areas immediately adjacent to the ingress or egress of the public place or place of employment.

* = required fields

PERSONAL INFORMATION

*First name:

Middle initial:

*Last name:

*SS#:

*E-mail:

*Address:

*City:

*State:

*Zip:

*Home phone:

Other phone:

POSITION INFO

*Position desired:

*Counties in which you are available to work

Allen:	Cuyahoga:
Fairfield:	Franklin:
Green:	Hamilton:
Lucas:	Montgomery:
Warren:

*Full-Time:

Part-time:

*Days/Hours available:

*Previously employed by RMS?

Yes: No:

*Are you authorized to work in the U.S.?

Yes: No:

*Have you lived in the state of Ohio for the past 5 consecutive years?

Yes: No:

*If no, please list location of all
residences over the past 5 years:
If yes please enter none:

*How did you hear about RMS?

*List any friends or relatives
working for RMS:
If none please enter none:

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?
Yes: No:

*Describe any accommodation(s) required:
working for RMS:
If none please enter none:

EDUCATION

High School

*Name/Location:

*# Years Attended:

*Did you graduate?

Yes: No:

*Subjects/Major:

*Degree or certificate received:

College

Name/Location:

# Years Attended:

Did you graduate?

Yes: No:

Subjects/Major:

Degree or certificate received:

G.P.A.:

Additional College or Graduate School

Name/Location:

# Years Attended:

Did you graduate?

Yes: No:

Subjects/Major:

Degree or certificate received:

Technical School

Name/Location:

# Years Attended:

Did you graduate?

Yes: No:

Subjects/Major:

Degree or certificate received:

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

EMPLOYMENT HISTORY

Beginning with the most recent, list all employers from 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.

EMPLOYMENT 1

*From (mo/yr) to (mo/yr):

*Title:

*Type of Business:

*Company:

*Address:

*Starting/Ending rate of pay:

*Supervisor/Title:

*Phone:

*May we contact:

Yes: No:

*Reason for leaving:

*Describe job duties:

EMPLOYMENT 2

From (mo/yr) to (mo/yr):

Title:

Type of Business:

Company:

Address:

Starting/Ending rate of pay:

Supervisor/Title:

Phone:

May we contact:

Yes: No:

Reason for leaving:

Describe job duties:

EMPLOYMENT 3

From (mo/yr) to (mo/yr):

Title:

Type of Business:

Company:

Address:

Starting/Ending rate of pay:

Supervisor/Title:

Phone:

May we contact:

Yes: No:

Reason for leaving:

Describe job duties:

EMPLOYMENT 4

From (mo/yr) to (mo/yr):

Title:

Type of Business:

Company:

Address:

Starting/Ending rate of pay:

Supervisor/Title:

Phone:

May we contact:

Yes: No:

Reason for leaving:

Describe job duties:

REFERENCES - Please provide 3 business references: (all fields required)

*Reference #1

Name:

Address:

Phone:

Years know:

*Reference #2

Name:

Address:

Phone:

Years know:

*Reference #3

Name:

Address:

Phone:

Years know:

SUPPLEMENTAL INFORMATION

Unless instructed otherwise, please provide the following information:

1. Do you have a valid driver's license?*

Yes: No:

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

*Date - Location - Description:
If none please enter none:

3. Have you ever been convicted of or pled no contest to a felony?* (NOTE: An affirmative answer will not automatically disqualify you as a candidate for employment): Yes: No:

*If yes, please explain:
If none please enter none:

Please read this statement carefully before signing.

I hereby certify that all of my 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 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, sexual preference, national origin, ancestry, religion, age, disability or military status.

This application is current for sixty (60) days. At the conclusion of this time, if I have not heard from RMS and still wish to be considered for employment, it will be necessary for me to fill out a new application.

I authorize RMS the right to contact and obtain information from all references, former employers, educational institutions and others provided on this application and release RMS and all other persons, corporations and organizations that furnish such information from liability for seeking, gathering and using such 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

AUTHORIZATION FOR RELEASE AND USE OF CONSUMER REPORTS

OHIO LAW REQUIRES THE COMPANY TO TAKE YOUR FINGERPRINTS SO THAT THE OHIO BUREAU OF CRIMINAL IDENTIFICATION AND INVESTIGATION CAN PERFORM A CRIMINAL RECORDS CHECK.

In addition to the criminal records check I understand that as a 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 the Company to request a report from the Ohio Bureau of Criminal Identification and Investigation, the Ohio Bureau of Motor Vehicles, and other Consumer Reporting Agencies to be used for employment related purposes, including hiring, promotion, transfer, or retention now or in the future.

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 action 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:

*Signature:

RMS Management, Inc. • 402 East Wilson Bridge Road, Suite A Worthington, Ohio 43085
Phone: 614-848-6640 • Fax: 614-847-0601