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Shared Living Provider Application

Name *

First

Last

Phone

Email

Address

Address Line 1

Address Line 2

City

State

Zip Code

County *

Position Sought *

Are you 18 years old or older? *

Yes
No

Date of Birth *

Are you eligible for employment in the United States? *

Yes
No

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

Yes
No

Previous Address

Please include all addresses in the past 5 years, from most to least recent.

Education *

Please indicate the highest level of education or training that you have obtained

Record of Conviction Have you ever been convicted of a crime other than minor traffic offenses? *

Yes
No

Yes ________ No ________ If yes, please explain:

Name | Reference 1

Please List 3 Reference Non-Related Individuals You have know for at least of 3 years

Phone Number | Reference 1

Personal or Professional Reference?

Personal
Professional

Name | Reference 2

Please List 3 Reference Non-Related Individuals You have know for at least of 3 years

Phone Number | Reference 2

Personal or Professional Reference?

Personal
Professional

Name | Reference 3

Phone Number | Reference 3

Personal or Professional Reference?

Personal
Professional

How Long Have You Lived at Your Current Residence?

Selected Value: 0

Do you own or rent your home? *

Own
Rent

If you answered rent, does your landlord allow you to have additional occupants living in the home? *

Yes
No

Are you Married

Yes
No

Has any person living with you ever been convicted of a crime other than minor traffic offense? *

Yes
No

Do you have a valid Ohio driver’s license with 4 or fewer points *

Yes
No

Do you have a car with current insurance coverage? *

Yes
No

Resume Upload *

Click or drag a file to this area to upload.

please upload your most updated resume

What qualities/experience do you have that would you make a good Shared Living Provider? *

Applicant’s certification of agreement I hereby certify that the facts set forth in the above employment application are true and complete to the best of my knowledge and authorize Equal Care Services to verify the accuracy and to obtain reference information on my work performance. I hereby release Equal Care Services from any/ all liability of whatever kind and nature, which, at any time could result from obtaining and having an employment decision, based on such information. I understand that, if employed, falsified statements of any kind and omissions of facts called for on this application shall be considered sufficient basis for dismissal. I understand that should an employment be extended to me, I accept that I will fully adhere to the policies and regulations of employment of Equal Care Services. However, I further understand that neither the policies, rules, regulations of employment, nor anything said during the interview process shall be deemed to constitute the terms of an applied employment contract. I understand that the employment offered is for a duration determined upon signing the contract and that I or the employer may terminate my employment, as long as it complies with the circumstances and conditions determined by the contract: *

Please Sign /Type Your Full Name in the Box Above