BUCKEYE RESIDENTIAL SOLUTIONS, L.L.C.

APPLICATION FOR EMPLOYMENT

TO ALL APPLICANTS:

Thank you for your interest in employment with Buckeye Residential Solutions, L.L.C.  In completing your application, please be sure to provide as much detail as possible and answer all questions thoroughly.   Please remember to type or print clearly and sign all pages that require a signature.

 

HIRING PROCESS:

When completed applications are received, they will be reviewed and you will be contacted if we have a match between your background and our needs.  You will receive notification from us by mail or phone.

 

All applicants under final consideration for employment with Buckeye Residential Solutions, L.L.C.  shall submit to a criminal background investigation as required by law.  In addition Buckeye Residential Solutions, L.L.C. will obtain certified abstracts from the Ohio Bureau of Motor Vehicles indicating a record of convictions for violation of motor vehicles laws.  By signing this form, the applicant gives consent for Buckeye Residential Solutions, L.L.C. to retrieve this information from the Ohio Bureau of Motor Vehicles.

 

 

_____________________________________                                  ________________________________

Printed Name                                                                                                   Date

 

_____________________________________

Signature

MINIMUM HIRING REQUIREMENTS:

In order to be eligible for employment with Buckeye Residential Solutions, L.L.C., applicants must meet the following requirements.  Please answer the following questions by circling YES or NO:

 

1.       Are you at least 18 years of age? 

YES    NO

2.       Do you have a high school diploma or a GED?

YES    NO

3.       Do you have a current, valid driver’s license with no more than 6 points on your driving record?

YES    NO

4.       Do you have proof of current, valid auto insurance

YES    NO

5.       Do you have a personal automobile that you are willing to use to transport consumers?

YES    NO

6.       Buckeye Residential Solutions, L.L.C. completes background checks on all employees and new hires.  Have you ever been convicted of or plead guilty to a felony?

YES    NO

 

Buckeye Residential Solutions, LLC

Job Description

 

Job Title: Residential Specialist

(Full and Part Time)

SUPERVISOR                   Residential Specialist

 

BASIC FUNCTIONS

 

To provide quality support services to consumers served by BRS that enhance physical, emotional, intellectual,  vocational, communication, and social skills according to the individual’s needs, abilities, and choices.  Other duties include keeping accurate records as required by BRS and any other governing agency such as ODDD, ODHS, and County Case Management.

 

Primary Responsibilities

 

1.        Follow established policies and procedures set by the agency.

2.        Assist consumers in meeting objectives of their Individual Service Plans, and to perform duties and tasks according to such plans.

 

3.        Monitor and ensure the consumer’s safety, health, and welfare.

 

4.        Maintain a clean and safe environment and be sensitive of the consumer’s and family’s needs.

 

5.        Assist consumers as needed according to daily individual schedules as directed in:

 

a.        Health care and personnel hygiene

b.        Meal Preparations and shopping

c.        Household tasks such as cleaning and laundry

d.        Recreation, social and leisure time skills

e.        Transportation as required

 

6.        Always maintain the highest standard of conduct and courtesy in dealing with consumers, family, staff and the community.  Promote positive interaction.

 

7.        Attend and participate in scheduled staff meetings, designated training and in-service sessions.

 

8.        Other Duties as assigned.

 

WORKING CONDITIONS:

May be assigned to weekend and evening schedule.  May be required to stay overnight and work some holidays, may be required to work in various locations according to consumer’s needs.  As a part-time employee, hours are not guaranteed and assigned as available.  Scheduled hours are based on consumer choice and needs.  Job will require sitting, standing, bending, lifting, pushing, and pulling, intermittently.

DESIRED QUALIFICATIONS:

Must be 18 years or older and be a high school graduate or equivalent.  Must possess a valid, current driver’s license and an acceptable police record.  Must have 0 to 5 years experience.

 

__________________________________________                            _______________________________

Staff Signature                                                                                       Date

PERSONAL INFORMATION

Date of application: _________________                       Date available to start work:______________

 

Name:_______________________________________________________________________________

               Last                                                             First                                                                     Middle

 

Address:______________________________________________________________________________

                   No.          Street                          Apt #               City                               State                     Zip

 

Email address:___________________________   How often do you check your email?______________

Telephone number (best way to reach you):________________________________________________

Position(s) applied for:___________________________________    Rate of pay expected  $__________

Have you ever worked for this agency before?  YES  NO (circle one)               If yes when?_____________

Have you ever applied for a position with this agency before?   YES  NO (circle one)  If yes when?__________

How did you learn of this opening? If a friend, list name of friend:______________________________

List friends or relatives working for this agency:_____________________________________________

AVAILABILITY

Please list your hours of availability:

 

Monday:         Available from:___________               Available until:_________________

Tuesday:         Available from:___________               Available until:_________________

Wednesday:   Available from:___________               Available until:_________________

Thursday:        Available from:___________               Available until:_________________

Friday:             Available from:___________               Available until:_________________

Saturday:        Available from:___________               Available until:_________________

Sunday:           Available from:___________               Available until:_________________

EMPLOYMENT HISTORY

Name of Employer:_________________________             Telephone No. (      )_____________________

Complete Address:_____________________________________________________________________

Fax Number:(        )_____________________________       Supervisor:____________________________

Job Title:_____________________________________       Dates of Employment: from _____to ______

Salary: beginning____________      ending__________       Full/Part Time (circle one)

Describe Responsibilities: _______________________________________________________________

Reason for Leaving:_____________________________________________________________________

Name of Employer:_________________________             Telephone No. (      )_____________________

Complete Address:_____________________________________________________________________

Fax Number:(        )_____________________________       Supervisor:____________________________

Job Title:_____________________________________       Dates of Employment: from _____to ______

Salary: beginning____________      ending__________       Full/Part Time (circle one)

Describe Responsibilities: _______________________________________________________________

Reason for Leaving:_____________________________________________________________________

Name of Employer:_________________________             Telephone No. (      )_____________________

Complete Address:_____________________________________________________________________

Fax Number:(        )_____________________________       Supervisor:____________________________

Job Title:_____________________________________       Dates of Employment: from _____to ______

Salary: beginning____________      ending__________       Full/Part Time (circle one)

Describe Responsibilities: _______________________________________________________________

Reason for Leaving:_____________________________________________________________________

 

EDUCATION

TYPE

NAME CITY AND STATE

YEARS COMPLETED

GRADUATED

DEGREE

MAJOR

HIGH SCHOOL

 

1    2    3    4

YES        NO

 

 

COLLEGE

 

1    2    3    4

YES        NO

 

 

POST GRADUATE

 

1    2    3    4

YES        NO

 

 

BUSINESS OR TRADE

 

1    2    3    4

YES        NO

 

 

OTHER

 

1    2    3    4

YES        NO

 

 

 

CERTIFICATION/LICENSURE REGRISTRATION

For many positions, state certification, licensure or registration requirements MUST be met.  Please complete the information below as it relates to the position(s) for which you have applied and include CPR, First Aid & Medication Administration if applicable.

 

Type of Certificate/Registration/License:

Authorizing Board or Agency/ Auth. State:

Expiration/Renewal Date:

 

 

 

 

 

 

 

 

 

 

REFERENCES

List three references, excluding former employers and relatives, who this agency has permission to contact.

Name:

Occupation:

Email:

Telephone Number:

1.

 

 

 

2.

 

 

 

3.

 

 

 

 

 

 

 

 

MISCELLANEOUS

1.       You will be required to attend all new staff training including orientation, MUI, OSHA, HIPPA, CPR, First Aid and Medication Administration training.  These classes are offered during normal business hours, 9am-5pm, Monday thru Friday.  Are you able to attend?

YES     NO

2.       Some sites require lifting, transferring consumers and use of a Hoyer lift.  Are you able to perform all of these job functions?      YES     NO

3.       Are you comfortable working at a site with pets?

YES     NO

4.       Are you willing to work at a site where the consumer smokes?

YES     NO

5.       Have you ever been convicted of or pleaded guilty to any of the following?

a.       A felony contained in the Ohio Revised Code:      YES    NO

b.      A crime contained in the Ohio Revised Code constituting a misdemeanor of the first degree on the first offense and a felony on subsequent offenses:    YES   NO

c.       A violation of an existing or former law of Ohio, and other state, or the United States, which offense is substantially equivalent to any of the offenses described in (A) or (B) above:     YES   NO

6.       Have you ever been discharged or requested to resign from a position?

YES     NO

7.       Have you ever had a certificate, license or registration revoked or suspended?

YES     NO

8.       Can you perform the job-related requirements of the specific job(s) for which you are applying?                            YES     NO

If you answered YES to questions 5,6 or 7, or NO to question 8; please explain FULLY, indicating (by number) to which question you are responding:

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

ADDITIONAL INFORMATION

Please summarize other experiences, skills, or qualifications which you feel would qualify you for the position(s) for which you have applied

 

 

 

PRE-EMPLOYMENT STATEMENT:

DISQUALIFYING OFFENSES FOR EMPLOYMENT

 

I will review the below list of disqualifying offenses and I am aware that if I have been convicted of or plead guilty to any of these offenses, I am not eligible for employment with Buckeye Residential Solutions, LLC.

Tier one:

• 2903.01 (aggravated murder);

• 2903.02 (murder);

• 2903.03 (voluntary manslaughter);

• 2903.11 (felonious assault);

• 2903.15 (permitting child abuse);

• 2903.16 (failing to provide for a functionally impaired person);

• 2903.34 (patient abuse and neglect);

• 2903.341 (patient endangerment);

• 2905.01 (kidnapping);

• 2905.02 (abduction);

• 2905.32 (human trafficking);

• 2905.33 (unlawful conduct with respect to documents);

• 2907.02 (rape);

• 2907.03 (sexual battery);

• 2907.04 (unlawful sexual conduct with a minor, formerly

corruption of a minor);

• 2907.05 (gross sexual imposition);

• 2907.06 (sexual imposition);

• 2907.07 (importuning);

• 2907.08 (voyeurism);

• 2907.12 (felonious sexual penetration);

• 2907.31 (disseminating matter harmful to juveniles);

• 2907.32 (pandering obscenity);

• 2907.321 (pandering obscenity involving a minor);

• 2907.322 (pandering sexually oriented matter involving a

minor);

• 2907.323 (illegal use of minor in nudity-oriented material

or performance);

• 2909.22 (soliciting/providing support for act of terrorism);

• 2909.23 (making terrorist threat);

• 2909.24 (terrorism);

• 2913.40 (Medicaid fraud); 2923.01 (conspiracy), 2923.02

(attempt), or 2923.03 (complicity) when the underlying

offense is any of the offenses or violations described in

paragraphs (E)(1)(a)(i) to (E)(1)(a)(xxix) of this rule; A \

conviction related to fraud, theft, embezzlement, breach of

fiduciary responsibility, or other financial misconduct

involving a federal or state-funded program, excluding the

disqualifying offenses set forth in section 2913.46 of the

Revised Code (illegal use of supplemental nutrition assistance \

program or women,infants, and children program benefits); or A

violation of an existing or former municipal ordinance or law of

this state, any other state, or the United States that is

substantially equivalent to any of the offenses or violations

described in paragraphs (E)(1)(a)(i) to (E)(1)(a)(xxxi) of this rule.

5123:2-2-02

 

Tier two:

• 2903.04 (involuntary manslaughter);

• 2903.041 (reckless homicide);

• 2905.04 (child stealing) as it existed prior to July 1, 1996;

• 2905.05 (criminal child enticement);

• 2905.11 (extortion);

• 2907.21 (compelling prostitution);

• 2907.22 (promoting prostitution);

• 2907.23 (enticement or solicitation to patronize a

prostitute; procurement of a prostitute for another);

• 2909.02 (aggravated arson);

• 2909.03 (arson);

• 2911.01 (aggravated robbery);

• 2911.11 (aggravated burglary);

• 2913.46 (illegal used of supplemental nutrition assistance

program or women, infants, and children program benefits);

• 2913.48 (workers' compensation fraud);

• 2913.49 (identity fraud);

• 2917.02 (aggravated riot);

• 2923.12 (carrying concealed weapon);

• 2923.122 (illegal conveyance or possession of deadly weapon

or dangerous ordnance in a school safety zone, illegal

possession of an object indistinguishable from a firearm in a \

school safety zone);

• 2923.123 (illegal conveyance, possession, or control of deadly

weapon or dangerous ordnance into courthouse);

• 2923.13 (having weapons while under disability);

• 2923.161 (improperly discharging a firearm at or into a

habitation or school);

• 2923.162 (discharge of firearm on or near prohibited premises);

• 2923.21 (improperly furnishing firearms to minor);

• 2923.32 (engaging in pattern of corrupt activity);

• 2923.42 (participating in criminal gang);

• 2925.02 (corrupting another with drugs);

• 2925.03 (trafficking in drugs);

• 2925.04 (illegal manufacture of drugs or cultivation of

marijuana);

• 2925.041 (illegal assembly or possession of chemicals for the

manufacture of drugs);

• 3716.11 (placing harmful objects in food or confection);

• 2923.01 (conspiracy), 2923.02 (attempt), or 2923.03

(complicity) when the underlying offense is any of the offenses

or violations described in paragraphs (E)(1)(b)(i) to

(E)(1)(b)(xxx) of this rule; or a violation of an existing or former

municipal ordinance or law of this state, any other state, or the

United States that is substantially equivalent to any of the

offenses or violations described in paragraphs (E)(1)(d)(i) to

(E)(1)(d)(xlii) of this rule 5123:2-2-02.

 

Tier three:

• 959.13 (cruelty to animals);

• 959.131 (prohibitions concerning companion animals);

• 2903.12 (aggravated assault);

• 2903.21 (aggravated menacing);

• 2903.211 (menacing by stalking);

• 2905.12 (coercion);

• 2909.04 (disrupting public services);

• 2911.02 (robbery);

• 2911.12 (burglary);

• 2913.47 (insurance fraud);

• 2917.01 (inciting to violence);

• 2917.03 (riot);

• 2917.31 (inducing panic);

• 2919.22 (endangering children);

• 2919.25 (domestic violence);

• 2921.03 (intimidation);

• 2921.11 (perjury);

• 2921.13 (falsification, falsification in theft offense, falsification to

purchase firearm, or falsification to obtain a concealed handgun

license);

• 2921.34 (escape);

• 2921.35 (aiding escape or resistance to lawful authority);

• 2921.36 (illegal conveyance of weapons, drugs, or other

prohibited items onto grounds of detention facility or institution);

• 2925.05 (funding of drug or marijuana trafficking);

• 2925.06 (illegal administration or distribution of anabolic

steroids);

• 2925.24 (tampering with drugs);

• 2927.12 (ethnic intimidation);

• 2923.01 (conspiracy), 2923.02 (attempt), or 2923.03

(complicity) when the underlying offense is any of the offenses

or violations described in paragraphs (E)(1)(c)(i) to

(E)(1)(c)(xxv) of this rule; or a violation of an existing or former

municipal ordinance or law of this state, any other state, or the

United States that is substantially equivalent to any of the

offenses or violations described in paragraphs (E)(1)(c)(i) to

(E)(1)(c)(xxvi) of this rule.

Tier four:

• 2903.13 (assault);

• 2903.22 (menacing);

• 2907.09 (public indecency);

• 2907.24 (soliciting after positive human immunodeficiency virus

test);

• 2907.25 (prostitution);

• 2907.33 (deception to obtain matter harmful to juveniles);

• 2911.13 (breaking and entering);

• 2913.02 (theft);

• 2913.03 (unauthorized use of a vehicle);

• 2913.04 (unauthorized use of property, computer, cable, or

telecommunication property);

• 2913.05 (telecommunications fraud);

• 2913.11 (passing bad checks);

• 2913.21 (misuse of credit cards);

• 2913.31 (forgery, forging identification cards);

• 2913.32 (criminal simulation);

• 2913.41 (defrauding a rental agency or hostelry);

• 2913.42 (tampering with records);

• 2913.43 (securing writings by deception);

• 2913.44 (personating an officer);

• 2913.441 (unlawful display of law enforcement emblem);

• 2913.45 (defrauding creditors);

• 2913.51 (receiving stolen property);

• 2919.12 (unlawful abortion);

• 2919.121 (unlawful abortion upon minor);

• 2919.123 (unlawful distribution of an abortion-inducing drug);

• 2919.23 (interference with custody);

• 2919.24 (contributing to unruliness or delinquency of child);

• 2921.12 (tampering with evidence);

• 2921.21 (compounding a crime);

• 2921.24 (disclosure of confidential information);

• 2921.32 (obstructing justice);

• 2921.321 (assaulting/harassing police dog or horse/service

animal);

• 2921.51 (impersonation of peace officer);

• 2925.09 (illegal administration, dispensing, distribution,

manufacture, possession, selling, or using any dangerous

veterinary drug);

• 2925.11 (drug possession other than a minor drug possession

offense);

• 2925.13 (permitting drug abuse);

• 2925.22 (deception to obtain dangerous drugs);

• 2925.23 (illegal processing of drug documents);

• 2925.36 (illegal dispensing of drug samples);

• 2925.55 (unlawful purchase of pseudoephedrine product);

• 2925.56 (unlawful sale of pseudoephedrine product);

• 2923.01 (conspiracy), 2923.02 (attempt), or 2923.03

(complicity) when the underlying offense is any of the offenses

or violations described in paragraphs (E)(1)(d)(i) to (E)(1)(d)(xli)

of this rule; or a violation of an existing or former municipal

ordinance or law of this state, any other state, or the United

States that is substantially equivalent to any of the offenses or

violations described in paragraphs (E)(1)(d)(i) to

(E)(1)(d)(xlii) of this rule 5123:2-2-02.

 

 

Tier five:

• 2925.11 (drug possession that is minor drug possession

offense);

• 2925.14 (illegal use or possession of drug paraphernalia);

• 2925.141 (illegal use or possession of marihuana drug \

paraphernalia); or a violation of an existing or former municipal

ordinance or law of this state, any other state, or the United

States that is substantially equivalent to any of the offenses or

violations described in paragraphs (E)(1)(e)(i) to (E)(1)(e)(iii) of

this rule.(2)

 

I will notify BRS within 14 calendar days if I am ever charged with, plead guilty to, or convicted of any disqualifying offenses. 

My signature below attests that I do not have any of these offenses on my record.

 

­­­­­­­­­­­­­­­­______________________________________                                           ______________________________

Applicant’s Signature                                                                                    Date

 

 

 

 

 

 

 

 

 

 

 

 

 

Applicant’s Agreement

I certify that I have read and understand the instructions and all other information on this application.  I grant permission to have this application and enclosures duplicated and distributed.  And, I certify that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief.

I understand that any false information, omissions or misrepresentations of fact called for in this application may result in refractions of my application or immediate discharge at any time during my employment.  I understand that, as a condition of initial or continued employment, I agree to submit to such lawful examinations, medical or substance abuse or others as may be required by the company.

I authorize Buckeye Residential Solutions, LLC and/or its agents, including consumer reporting bureaus to verify any of this information by searching appropriate information and record sources.  I authorize all employers, persons, schools, companies, law enforcement authorities, and state agencies to release information concerning my background and hereby release those parties from any liability for any damage whatsoever for issuing this information.

I confirm that I meet all the requirements as stated on the job posting(s) for the position(s) for which I am applying.  I am able to perform all the duties as described.

I understand and agree that, as a condition of employment, I shall meet and maintain all required standards of my position which involves certification, registration, licensure and training.

 

 

_________________________________________                   ______________________________

Printed Name                                                                                                    Date

 

 

_________________________________________                  

Signature

Buckeye Residential Solutions, LLC

855 Jones Avenue • Ravenna, Ohio 44266 • 330.839.8026 (Office)

AUTHORIZATION TO RELEASE INFORMATION

 

TO: H.R. DEPARTMENT

 

Please be advised that I have applied for a position with Buckeye Residential Solutions, LLC.  I have been requested or provide information for their use in reviewing my background and qualifications.  Therefore, I authorize the investigation of my past and present health, character, education, military and employment qualifications.

The release in any manner of all information by you is hereby authorized whether such information is of record or not, and I do hereby release all persons, agencies or firms from any liabilities resulting from providing such information.

This information is valid for 90 days from the date of my signature below.  Please keep this copy of my release for your files.  Thank you for your cooperation.

 

 

______________________________                                 _______________________

Signature                                                                              Date

 

 

______________________________                                 _________________________

Witness                                                                                 Date