Allen County 419 | 999 0360 Phone Hours: Monday Friday
951 Commerce Pkwy., P.O. Box 4506 419 | 999 0205 Fax 7:30 a.m. 4:30 p.m.
Lima, Ohio 45802-4506
Section to be completed by employer:
Position: ___________________________
Hourly Wage: _______________________
Start Date: __________________________
*Please advise all candidates that a representative from Ohio Means
Jobs will be contacting them regarding program eligibility
On-the-Job Training (OJT) Screening Sheet
Name:_______________________________________________________ SSN:_____________________
Address: _________________________________ City _______________ State ______ ZIP_________
Birthdate: ______________ Home Number: ____________________ Cell Phone: __________________
E-Mail: ___________________________________
Do you reside in Allen County? Yes No Are you at least 18 years of age? Yes No
Are you a United States Citizen or eligible to work in the United States? Yes No
Males born after 1960 Have you registered with Selective Service? Yes No
Total number of people in household? ________ Number of minor children living in the household? _______
Are you currently employed? Yes No
If yes, what is your hourly wage? __________ Average hours per week? ________
If no, list your most recent employer _____________________ End date with that employer __________
If married, is your spouse employed? Yes No
Spouse wage per hour? ____________ Average hours per week? ____________
Are you laid off? Yes No
If yes, from what company? _______________________ Layoff date: __________ Wage at Layoff: _______
Recall expected? Yes No Expected date of return if known? _____________
Do you have an Associates, Bachelor’s, or Master’s degree or a recognized certification? Yes No
If yes, list degree or certification and year attained: ____________________________________________