* = Required Information

ADDS Employment Application Form
Please complete the information below:
 
Date: * Phone #: S.S.N.: *
Name: * Address: *
City: * States: * Zip Code: *
Have you previously been employed by Andrew Developmental Disabilities Services, LLC. ?
NoYes       When ?  
Please give the name(s) of persons on our company you know:
How did you hear about our company?
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WHAT POSITION DO YOU DESIRE: FULL-TIMEPART-TIME
SHIFT: MONDAY THRU FRIDAYWEEKENDS 1st SHIFT2nd SHIFT3rd SHIFT
Pay Rate desired? Per hourPer visitAnnually
Are you legally authorized to work in the United States?    YesNo
    If yes, provide proof:   
Have you been a resident of the State of Ohio for the past five (5) years?    YesNo
    If not, list the cities and states you have resided in during the past five (5) years:   
City: State: City: State:
In case of emergency notify: Phone #:
Have you served in the U.S. Armed Forces?    YesNo
Branch of Service: Rank at Discharge:
Date entered Service: Date of Discharge:
Valid Ohio Driver License #:
List all driving offenses during the past 3 years:
EDUCATION:
Do you have a HIGH SCHOOL DIPOLMAG.E.D. CERTIFICATENONE ?
Name of high school or G. E.D. program:
City: State: Zip Code:
College or University Attended:
City: State: Zip Code:
List additional training or educational certificates/degrees received related to this field:
PROFESSIONAL AND CHARACTER REFERENCES:
List at least three (3) references you have known for one (1) year or more. Please DO NOT list relatives.
Name: Phone #:
Address: Relationship:
Name: Phone #:
Address: Relationship:
Name: Phone #:
Address: Relationship:
EMPLOYMENT HISTORY:
List all present and past employment, including any work in the Developmental Disability field, beginning with the most recent job. You may attach your resume as well.
Company:
Address: City: State: Zip Code:
Phone #: Position: Supervisor:
Dates Employed: to Reason for Leaving:
Describe the work you performed:
Company:
Address: City: State: Zip Code:
Phone #: Position: Supervisor:
Dates Employed: to Reason for Leaving:
Describe the work you performed:
Company:
Address: City: State: Zip Code:
Phone #: Position: Supervisor:
Dates Employed: to Reason for Leaving:
Describe the work you performed:
Company:
Address: City: State: Zip Code:
Phone #: Position: Supervisor:
Dates Employed: to Reason for Leaving:
Describe the work you performed:
Please describe, in your own words, what a developmental disability is and how you feel persons with developmental disabilities should be treated in our society:
Why are you interested in this job?
What qualities do you possess that will benefit the individuals we serve?
If you were developmentally disabled, what would you expect from someone who was hired to come into your home to provide supported living services to you?
BACKGROUND RESEARCH RELEASE:
Please read this section carefully and acknowledge your understanding by signing your name in the space below.
* I certify that all of the statements made by me on this application for employment are true, correct, and complete to the best of my knowledge.
1. Consent to Conduct Background Investigation.
* As a condition of and in consideration for ADDS, LLC consideration of this application, I give permission to ADDS, LLC to investigate my personal and employment history. I understand that this background investigation will include, but not be limited to, verification of all information on this application, interviews with past employers, criminal records check, Ohio Department of Developmental Disabilities Abuser Registry, and the State of Ohio Nursing Aide Abuser Registry. I further give permission to ADDS, LLC to conduct this investigation and to discuss the results of this investigation in connection with my application of employment.
2. Consent to Contact Past Employers.
* I give permission to ADDS, LLC to contact all employers listed in this application (except those specifically excluded) for references. Further give permission to all current or previous employers and/or managers or supervisors to discuss my relevant personal and employment history with ADDS, LLC consent to the release of such information orally or in writing, and hereby release them from all liability and agree not to sue them for defamation or other claims based upon any statements they make to any representative of ADDS, LLC I further waive all rights I may have under state law to receive a copy of any written statement provided by any of my former employers to ADDS, LLC I further agree to indemnify all past employers for any liability they may incur because of their reliance upon this release.
3. Consent to Contact Government Agencies.
* I give permission to any agent, attorney or representative of ADDS, LLC to receive a copy of any information obtained in the file of any federal, state, or local court, governmental agency, law enforcement agency or investigator concerning or relating to me. I further consent to the release of such information and waive any right under state law concerning notification of the request for a release of such information. In the event a state law does not provide for prospective employers to have access to information, I hereby delegate ADDS, LLC as my agent for receipt of information. I understand that the scope of this investigation will be limited to criminal and/or civil records that relate to my honesty, integrity and/or abilities.
4. Cooperation with Investigation.
* I agree to fully cooperate in ADDS, LLC background investigation, and to sign any waivers or releases that may be necessary to obtain access to relevant information. In the event that any former employer or federal, state, or local governmental agency will not release reference information or criminal history information directly to the employer, I agree to personally request such information to the extent of the law.
5. Falsification Statement
* I understand that any falsification or willful omission of fact made in this application or in connection with any background investigation may be sufficient grounds for rejection of this application, or, if discovered after an offer or employment, for immediate dismissal.
EMPLOYMENT APPLICATION & AT-WILL ACKNOWLEDGMENT:
* If I am employed, I agree that in consideration for my employment, I will conform to the rules and regulations of ADDS, LLC . I understand that those rules and regulations may be altered, amended or repealed by ADDS, LLC at any time, at ADDS, LLC's sole option and without any prior notice to employees.
* I acknowledge that if I am employed, my employment and compensation can be terminated at any time, with or without cause or notice, at the option of either ADDS, LLC or myself. I understand that no representative of ADDS, LLC has any authority to enter into any agreement for employment for any specified period of time, to assure any benefits or terms and conditions of employment, or to make any agreement contrary to the forgoing, except the President/CEO of ADDS, LLC, who may only do so in writing.

* Security Code