Lilly May Services for Individual with Developmental Disabilities (LMSIDD)

PO Box 317826

Phone: 5132276573

Fax:5138731383

Online Employment Application form

First Name *

Middle Name

Last Name *

Applicant Information

Street Address *

City *

State *

Zip *

Home Phone *

Other Phone

E-mail *

No. Years?*

Position Applied for *

First Date Available

Last Date Available

Driver License

Social Security Number

Are you a citizen of the United States?*

If no, are you authorized to work in the U.S.

Have you ever worked for LMSIDD? *

If so, When?

Have you ever been convicted of a felony?*

Have you had an Ohio BCI recently? *

If yes, explain

If so, When?

Education

High School

From

To

College

From

To

Other

Address

Graduate?

Address

Graduate?

Degree

Address

Other Training (Graduate, Technical, Vocational)

Certifications, Awards, Honors, Special Achievements

References

Full Name

Full Name *

Relationship

Relationship *

Company Name

Phone

Phone *

Address *

Full Name *

Relationship *

Company Name

Phone *

Address *

Full Name

Relationship

Company Name

Phone

Address

Emergency contacts

Full Name *

Adress *

City/State *

Full Name *

City State *

Address *

Full Name

City/State

Adress

Relationship *

Daytime Phone *

Relationship *

Evening

Daytime Phone *

Relationship

Evening

Daytime Phone

Previous Employment

Company Name

Address

Phone

Supervisor

Job Title

Responsibilities

From

To

Reason for leaving

May we contact your previous supervisor for a reference?

Company Name

Address

Phone

Supervisor

Job Title

Responsibilities

From

To

Reason for leaving

May we contact your previous supervisor for a reference?

Company Name

Address

Phone

Supervisor

Job Title

Responsibilities

From

To

Reason for leaving

May we contact your previous supervisor for a reference?

Additional Data

Who referred you to our company?

Do you have friends or relatives who work here? If yes list below *

Are you at least 18 years of age? *

How will you get to work? *

Are you able to perform the essential functions of the job you seek with or without reasonable accommodation? *

If no, what reasonable accommodation would you request?

Are you willing to work any shift, including nights and weekends? If no, please state limitations *

If applicable, are you available to work overtime? *

Applicant Skills

Military Service

Branch *

From

Rank at Discharge

To

Type of Discharge

If other than honorable, explain

Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge.

If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release

Signature:*

Date: *