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 www.omjallen.com
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: ____________________________________________
