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6450 Wiehe Road EMPLOYMENT APPLICATION PERSONAL INFORMATION (The Village of Golf Manor)

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6450 Wiehe Road
Golf Manor, OH 45237
513-531-7491
513-531-4404 Fax
www.golfmanoroh.gov
EMPLOYMENT APPLICATION
AN EQUAL OPPORTUNITY EMPLOYER
Qualified applicants are considered for all positions without regard to race, color, religion, sex,
sexual orientation, national origin, marital or veteran status, or disability.
PERSONAL INFORMATION
Name: ________________________________________________________ SS#: ____________________________
Last First Middle
Address: _______________________________________________________________________________________________
Street City State Zip Code
Home Telephone: (_________)_______________________ Mobile: (__________)___________________
Have you ever been employed by the Village of Golf Manor? Yes No
If yes, please provide dates previously worked and position(s) held: ________________________________________________
Have you ever been convicted of a felony? Yes No
If yes, please provide date, place, and charge:
_________________________________________________________________
JOB INTEREST
Position of Interest: ____________________________________________________________
Date Applied: ______________________________ Approximate Date of Availability:
_____________________________
EDUCATION
Circle highest level accomplished (elementary and secondary): 1 2 3 4 5 6 7 8 9 10 11 12
Circle highest level accomplished: College Undergraduate: 1 2 3 4 Graduate School: 1 2 3 4
TYPE OF SCHOOL
NAME & LOCATION
OF SCHOOL
DEGREE AREA OF STUDY
HIGH SCHOOL
Graduate: Yes No
or
G.E.D.: Yes No
COLLEGE, UNIVERSITY,
BUSINESS, TECHNICAL,
VOCATIONAL, OR
MILITARY ACADEMY
Dates Attended (Mo./Yr. To Mo./Yr.):
Degree:
GRADUATE OR
PROFESSIONAL SCHOOL
Dates Attended (Mo./Yr. To Mo./Yr.):
Degree:
Are you currently enrolled in an educational program? Yes No If yes, what is your main course of study and
where are you attending? ________________________________________________________________________________
LICENSES, CERTIFICATIONS, REGISTRATIONS
I possess: a valid Driver’s License __________________ a valid Commercial Driver’s License _________________
Please list State_______________ Number: _____________________ Expiration Date: _
_________________________
PROFESSIONAL/TECHNICAL LICENSES AND REGISTRATIONS
TYPE STATE NUMBER EXPIRATION DATE (IF ANY)
MILITARY SERVICE
Were you in the U.S. Armed Forces: Yes No If yes, what branch? ___________________________________
Dates of Services: From: ___________________ to _____________________ Rank: ______________________________
Technical Specialization: __
_______________________________________________________________________________
AWARDS, HONORS, ACHIEVEMENTS, INTERESTS
Please list any awards, honors, achievements, volunteer or community services activities, special interests, hobbies, or any organizations
of which you are/have been a member. Please indicate any positions of leadership previously/currently held.
TRAINING AND OTHER QUALIFICATIONS
Please list any training you feel is relevant to the position for which you are applying:
SUBJECT AREA OF TRAINING ORGANIZATION PROVIDING TRAINING YEAR TRAINING RECEIVED
Please use this area to briefly describe any additional information or special qualifications you have for the position for which you are
applying. Please be sure to include any special machinery, office equipment, software, tools, vehicles, or other job- related items.
EXPERIENCE
List your work experience starting with your current/most recent employer. Please include all employment whether full-time, part-time,
seasonal, or temporary during the past ten years. You may include additional experience beyond the past ten years if you desire and you
are encouraged to do so if it is related to the employment you are seeking. You may attach additional pages, if necessary. Please not use a
resume as a substitute for completing this section; however, you may attach a resume to supplement the information contained within
this employment application.
Current/Most Recent Employer: ___________________________________________________________________________
Address: ______________________________________________________________________________________________
Street City State Zip Code
Supervisor’s Name: ____________________________________________ Phone Number:(______)_____________________
Position Held: ______________________________________________________ Salary: _____________________________
Dates of Employment: _________ to __________ Type of Employment: Full-Time Part-Time Seasonal/Temporary
Description of duties and responsibilities:
Reason for Leaving:
The Village of Golf Manor may contact former employers. If you prefer that we do not contact your present employer until such time as a
conditional offer of employment is made, please check this block:
Previous Employer: _____________________________________________________________________________________
Address: ______________________________________________________________________________________________
Street City State Zip Code
Supervisor’s Name: ____________________________________________ Phone Number:(______)_____________________
Position Held: ______________________________________________________ Salary: _____________________________
Dates of Employment: _________ to __________ Type of Employment: Full-Time Part-Time Seasonal/Temporary
Description of duties and responsibilities:
Reason for Leaving:
EXPERIENCE (continued)
Previous Employer: _____________________________________________________________________________________
Address: ______________________________________________________________________________________________
Street City State Zip Code
Supervisor’s Name: ____________________________________________ Phone Number:(______)_____________________
Position Held: ______________________________________________________ Salary: _____________________________
Dates of Employment: _________ to __________ Type of Employment: Full-Time Part-Time Seasonal/Temporary
Description of duties and responsibilities:
Reason for Leaving:
Previous Employer: _____________________________________________________________________________________
Address: ______________________________________________________________________________________________
Mailing Address City State Zip Code
Supervisor’s Name: ____________________________________________ Phone Number:(______)_____________________
Position Held: ______________________________________________________ Salary: _____________________________
Dates of Employment: _________ to __________ Type of Employment: Full-Time Part-Time Seasonal/Temporary
Description of duties and responsibilities:
Reason for Leaving:
REFERENCES
Please list three individuals, other than relatives, whom we may contact as references regarding your character, ability, or experience.
NAME
HOME PHONE NUMBER
(WITH AREA CODE)
WORK PHONE NUMBER
(WITH AREA CODE)
TYPE OF REFERENCE
(PERSONAL, PROFESSIONAL, EDUCATIONAL,
ETC.)
CERTIFICATION AND STATEMENT OF UNDERSTANDING
I certify that all information provided in this employment application and its addenda is true and complete to the best of my knowledge. I
understand that the Village of Golf Manor may investigate this information and I understand that any misrepresentation or false
information in this application and its addenda may lead to withdrawal of any employment offer or termination after employment.
Signature: Date:
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ACKNOWLEDGEMENT & RELEASE
(Please read thoroughly before signing.)
I hereby acknowledge that I, voluntarily and of my own free will, have applied for employment with the Village of Golf Manor with the understanding that
the Village may use a variety of screening procedures to evaluate my qualifications and suitability for appointment. I have been advised that these
screening procedures may include, but are not limited to, interviews, criminal record checks, driving record checks, polygraph examinations, written
testing, reference checks, background investigations, psychological evaluations, medical examinations, and drug testing. I hereby understand that I would
not be required to actually participate in a psychological evaluation, medical examination, or drug test until after I have received a conditional offer of
employment. I also acknowledge that I may also be subject to other screening procedures, not specifically listed above. I further acknowledge that any
such screening procedures, as reasonably required by the Village of Golf Manor, are a prerequisite to my appointment to a position with the Village of
Golf Manor.
In addition, I also hereby understand that the Village of Golf Manor cannot guarantee the confidentiality of the results of, or information obtained
through, the aforementioned screening procedures. Rulings of the Ohio Supreme Court relative to the Public Records Act indicate that, with certain
enumerated exceptions, records maintained by a governmental entity are a matter of public record and, should a proper request be made by a member
of the public for such records, the governmental entity would be required to make such records available to that member of the public within a
reasonable period of time. Employment-related documents, with the exception of medical records, maintained by the Village relative to the
aforementioned screening procedures do not appear to fall within any of the enumerated exceptions.
I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with the Village of Golf Manor is of
an “at will” nature, which means that the Employee may resign at any time and the Employer may discharge the Employee at any time for any reason,
except as otherwise determined by the Charter and Ordinances of the Village of Golf Manor or applicable law. It is further understood that this “at will”
employment relationship may not be changed by any written document or contract unless such change is specifically acknowledged in writing by the
authorized executive of the Village.
Therefore, in consideration of my employment application being reviewed and considered by the Village of Golf Manor I, being at least 18 years of age
and under no legal disability on behalf of my heirs and assigns, hereby release and agree to hold harmless, the Village of Golf Manor and any of its agents,
employees, or related officials from any and all liability, whatever the type and nature, resulting from the administration of any such screening procedures
and/or the release of the results therefrom
.
Signature of Candidate: Date:
Signature of Witness: Date:
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PRE-EMPLOYMENT DRUG TESTING CONSENT
I understand that, as a candidate for employment with the Village of Golf Manor, I must, in order to be appointed to a position with the Village of Golf
Manor, voluntarily consent to, and pass, a drug screening to detect the presence of drugs in my system. I also understand that I will not actually be
administered such a test until I have received a conditional offer of employment. I further understand that my application for employment will be
rejected if I decline to sign this consent and thereby decline to be tested, if my test results are confirmed to be positive for the presence of illegal drugs or
legal drugs for which I cannot submit sufficient proof that such drugs were legally obtained and used, or if masking agents are detected in any specimen I
provide as part of the testing procedure.
I hereby knowingly and voluntarily consent to participate in a substance abuse screening and authorize the Village of Golf Manor to conduct, through its
designated testing laboratory or other licensed/certified medical professionals/technicians, said screening. In addition, I authorize the designated testing
laboratory or other licensed/certified medical professionals/technicians to release any and all information regarding the test(s), including results, to the
Village of Golf Manor and its representative. I further release the Village of Golf Manor, its officers, directors, employees, agents, representatives from
any and all claims, suits, causes of action, liability, and damages arising from my submitting to the test(s) and from the information obtained from the
test(s).
Signature of Candidate: Date:
Signature of Witness: Date:
I refuse to consent to a drug screening.
Signature of Candidate: Date:
Signature of Witness: Date:
DRUG AND ALCOHOL TESTING
ACKNOWLEDGEMENT, RELEASE AND CONSENT
I acknowledge that the Village of Golf Manor has an Employee Drug Testing Program, which requires employees to submit to drug and/or alcohol testing
under the following circumstances: when the Village has reasonable suspicion to believe that an employee is under the influence of illegal drugs or alcohol
while on Village premises or on Village business; following a serious violation safety policies, rules, and regulations; or following a work-related accident
resulting in any of the following: bodily injury (other than minor abrasions/contusions) to the employee or any third party requiring off-site medical
attention; issuance of a traffic citation to the employee for a moving violation in connection with a vehicular accident; vehicular damage in apparent
excess of $1,000; non-vehicular property damage in apparent excess of $500; any accident involving fatalities.
I understand that should I be appointed to a position with the Village of Golf Manor, the Village may request my participation in a drug and/or alcohol test
one or more times during my employment with the Village. I further understand that I would be subject to appropriate disciplinary action including
suspension or dismissal if the test results are positive, if masking agents are detected in specimens provided by me in conjunction with the testing
procedure, or if I refused to be tested.
I hereby knowingly and voluntarily consent to further drug and/or alcohol testing after appointment to a position with the Village of Golf Manor, based
upon the terms and conditions specified above, during the term of my employment with the Village of Golf Manor I authorize the Village to conduct,
through its designated testing laboratory or other licensed/certified medical professionals/ technicians, urinalysis, blood, saliva, or breath testing. In
addition, I authorize the designated testing laboratory or other medical professionals/technicians to release any and all information regarding the tests,
including their results, to the Village of Golf Manor and its representatives. I further release the Village of Golf Manor, its officers, directors, employees,
agents, representatives from any and all claims, suites, causes of action, liability, and damages arising from my submitting to the tests and from the
information obtained from the tests.
Signature of Candidate: Date:
Signature of Witness: Date:
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6450 Wiehe Road EMPLOYMENT APPLICATION PERSONAL INFORMATION (The Village of Golf Manor)

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Completed 27 January 2021

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