APPLY NOW – Community Supports

EQUAL OPPORTUNITY EMPLOYER: It is our policy to abide by all Federal, Sate, and local laws prohibiting employment discrimination solely on the basis of a person's race, color, creed, national origin, religion, age (over 40), sex, marital status, sexual preference or physical handicap, except where a reasonable, bona fide occupational qualification exists.

Personal Information

Name *

First

Middle

Last

Maiden Name (If applicable)

Social Security Number *

Driver's License Number *

If other than Ohio, please list issuing state

Phone Number *

Please include area code

Email *

Address and Availability

Home Address *

Address Line 1

Address Line 2

City

State

Zip Code

Have you resided in Ohio for the past five years? *

Yes
No

How did you find out about this position?

*Current employee who referred you?

Position for which you are applying? *

Support Provider
Program Coordinator Assistant
House Manager
Other

Are you seeking full-time or part-time employment?

Full Time
Part Time

Full-time employment is considered no less than 40 hours per week

Work Availability

	No Availability	First Shift (morning)	Second Shift (evening)	Third Shift (overnight)
Sunday	No AvailabilitySunday No Availability	First Shift (morning)Sunday First Shift (morning)	Second Shift (evening)Sunday Second Shift (evening)	Third Shift (overnight)Sunday Third Shift (overnight)
Monday	No AvailabilityMonday No Availability	First Shift (morning)Monday First Shift (morning)	Second Shift (evening)Monday Second Shift (evening)	Third Shift (overnight)Monday Third Shift (overnight)
Tuesday	No AvailabilityTuesday No Availability	First Shift (morning)Tuesday First Shift (morning)	Second Shift (evening)Tuesday Second Shift (evening)	Third Shift (overnight)Tuesday Third Shift (overnight)
Wednesday	No AvailabilityWednesday No Availability	First Shift (morning)Wednesday First Shift (morning)	Second Shift (evening)Wednesday Second Shift (evening)	Third Shift (overnight)Wednesday Third Shift (overnight)
Thursday	No AvailabilityThursday No Availability	First Shift (morning)Thursday First Shift (morning)	Second Shift (evening)Thursday Second Shift (evening)	Third Shift (overnight)Thursday Third Shift (overnight)
Friday	No AvailabilityFriday No Availability	First Shift (morning)Friday First Shift (morning)	Second Shift (evening)Friday Second Shift (evening)	Third Shift (overnight)Friday Third Shift (overnight)
Saturday	No AvailabilitySaturday No Availability	First Shift (morning)Saturday First Shift (morning)	Second Shift (evening)Saturday Second Shift (evening)	Third Shift (overnight)Saturday Third Shift (overnight)

Select all days and shifts you are available

If hired, can you provide proof of citizenship and/or verification of your legal right to work in the United States? *

Yes
No

Were you ever previously employed by Community Supports, Inc. (CSI)? *

Yes
No

If you answered yes to the previous question, please list the dates of previous CSI employment:

Have you ever been convicted of or pled no contest to a felony and/or misdemeanor? *

Yes
No

Applicant must disclose convictions that have been sealed. (Conviction will not necessarily disqualify an applicant) For purposed of this question "conviction" includes a plea of no contest, a finding of guilty by a judge or jury and bond forfeiture.

If you answered yes to the previous question, please list the date(s) and name(s) of offense(s):

Date - Read Below* *

*This statement is to verify that as of today's date (selected above), I have not been convicted of, or pleaded guilty to any disqualifying offense(s), which would prohibit me from employment with Community Supports, Inc. I also agree, effective the date above, that if I am employed, I will notify Community Supports, Inc. if I receive formal charges, convictions, or make a guilty plea to any of the disqualifying offenses mandated by Ohio Department of Developmental Disabilities within five calendar days.

Have you ever been the subject (PPI) of a Major Unusual Incident (MUI) investigation through Developmental Disability Services or law enforcement? *

Yes
No

If you answered yes to the previous question, please explain:

Do you have any physical limitations in performing the job duties for the position you are applying for? *

Yes
No

If you answered yes to the previous question, please explain the necessary accommodation:

Do you have a current and valid driver's license? *

Yes
No

This is required for employment

Do you currently have liability insurance on your vehicle? *

Yes
No

This is required for employment

Do you have 5 points or fewer on your driver's license? *

Yes
No

Not eligible for employment if you have 6 points or greater

Education and Training

Have you earned your high school diploma or GED? *

Yes
No

Copy of diploma or GED required for employment

Have you earned a degree from a college or university?

Yes
No

If you answered yes to the previous question, please list the college attended and degree earned:

List any other education, training, special skills, certifications/licenses that you possess which might be related to this job:

Work Experience

List all work experience during the past 5 years beginning with the most recent place of employment

Name of Employer 1 *

City *

State *

Job title *

Please provide a brief description of your job duties: *

Beginning date of employment *

Ending date of employment *

Ending pay *

Employer's phone number *

Please include area code

Employer #2

Name of Employer 2

City

State

Job title

Please provide a brief description of your job duties:

Beginning date of employment

Ending date of employment

Ending pay

Employer's phone number

Please include area code

Employer #3

Name of Employer 3

City

State

Job title

Please provide a brief description of your job duties:

Beginning date of employment

Ending date of employment

Ending pay

Employer's phone number

Please include area code

References

Name of reference 1 *

First

Last

Phone

Is this person a professional or personal reference? *

Professional reference
Personal reference

Name of reference 2 *

First

Last

Phone

Is this person a professional or personal reference? *

Professional reference
Personal reference

Do you have a resume you wish to include?

Click or drag a file to this area to upload.

Resumes are required if applying for the Program Coordinator position