Name: Shelby County Board of Developmental Disabilities
Address: 1200 S. Children’s Home Rd., Sidney, Ohio, 45365
Telephone: 937-497-8155

Any information given on this form will be regarded as strictly confidential. The completion of this Application for Employment does not indicate that there are any positions available, nor does it in any way obligate the Shelby County Board of Developmental Disabilities.
Personal Information
Today's Date*
MM slash DD slash YYYY
Name*
First Middle Last
Address*
Street Address City State ZIP Code
Home Phone*
Cell Phone
Email*
Social Security: If selected for an interview you will need to provide your social security number at that time.

Position Applied for and/or Area of Interest
Position(s) of Interest*
I am interested in:*
- Full Time
- Part Time
- Substitute
I am interested in working with:*
- Children
- Custodial
- Community Education & Outreach
- SSA
When could you report to work?*
MM slash DD slash YYYY

References
May we contact your present employer?*
- Yes
- No
Please list three individuals, other than relatives, we may contact for a professional recommendation.
Reference #1
Name*
Relationship*
Address*
Street Address City State ZIP Code
Phone*
Reference #2
Name*
Relationship*
Address*
Street Address City State ZIP Code
Phone*
Reference #3
Name*
Relationship*
Address*
Street Address City State ZIP Code
Phone*

Ohio Civil Service Application
Please submit one application per position or examination to the address indicated on the job posting or examination announcement. Copies are acceptable. Applications lacking sufficient information will not be processed. Please ensure your application is received or postmarked by the closing date, as required by the hiring agency. Please be sure to complete the entire application. Also note that, once submitted to a governmental agency, this completed form will be subject to all applicable public record laws.
Name*
First Middle Last
Month of Birth*
Day of Birth*
Address*
Street Address City State ZIP Code
County*
Email*
Home Phone
Alternate Phone
Do you have a driver's license?*
- Yes
- No
Driver's License Number
Class
State
Do you have a legal right to work in the U.S.?*
- Yes
- No

Education
High School Name*
Location (City, State)*
City State
Did you graduate?*
- Yes
- No
Year Completed*
Obtained GED?
- Yes
- No
School Name (College/University)
Location (City, State)
City State
Year Completed
Did you graduate?
- Yes
- No
Degree Received
Major
Number of Quarters / Semester Hours Completed
School Name (College/University)
Location (City, State)
City State
Year Completed
Did you graduate?
- Yes
- No
Degree Received
Major
Number of Quarters / Semester Hours Completed

Certificates & Licenses
Type:
License Number:
Issuing Agency:
Type:
License Number:
Issuing Agency:
Skills
Typing Speed:
Data Entry Speed:
Computer Skills:
Other Skills:
Language(s):

The purpose of questions 1–7 is to obtain information relevant to employment with the state of Ohio. Responses to these questions are required.
1. Summary of Qualifications*
In the area below, briefly describe the experience, education, training and other factors that qualify you for the position or examination for which you are applying. Refer to the Minimum Qualifications and any position-specific qualifications posted for this position or examination.
2. Relevant Coursework or Schoolwork*
Please list below the specific course work areas at the high school level or beyond relevant to the position or examination for which you are applying. Also indicate the number of courses you have successfully completed in each area. NOTE: A transcript may not be substituted for this section, although you may be required to submit a transcript.
3. Are you a current state of Ohio employee?*
- Yes
- No
4. If you are a current state of Ohio employee, provide Employee ID Number. If not, indicate N/A:*
5. If you are not a current state of Ohio employee, have you ever been employed by the state of Ohio? (If you are a current state of Ohio employee, select N/A)*
- Yes
- No
- N/A
6. If you were previously employed by the state of Ohio, please choose one of the following:*
- Employment ended on or after 12-01-2004
- Employment ended prior to 12-01-2004
- N/A Not previously employed by the state of Ohio or current state employee
7. How did you learn about this employment or examination opportunity?*
Certification
Pursuant to Ohio Administrative Code Section 5123:2-2-02, the Shelby County Board of Developmental Disabilities is required to conduct background investigations for purposes of employment. Please note that per 5123:2-2-02, there are five tiers of disqualifying offenses with corresponding time periods that preclude an applicant from being employed with this agency. Therefore, all applicants under final consideration will be required to submit to a background check through the Bureau of Criminal Identification and Investigation. For more information, please review OAC 5123:2-2-02. Your signature below verifies that you understand our requirement to conduct background checks as part of the hiring process.

I certify that the answers I have made to all of the questions in this application are true and complete to the best of my knowledge. I understand that if this application is not completed in its entirety, it will not be processed and I will be automatically disqualified. I understand that I am responsible for the correctness of this application. I also understand that a background check may be required prior to employment and that, in accordance with the Drug-Free Workplace Program, drug testing may be required. I waive all provisions of law forbidding colleges or universities which I attended, or past employers, from disclosing any information which they acquired relevant to my employment. I consent that they may disclose such information to the Human Resources Division, Ohio Department of Administrative Services, and/or the agency that holds the vacancy for which I am applying and to appropriate officials for recruitment purposes. I understand that any offer of employment is conditional upon proof of legal authorization to work in the United State as required by the Immigration Reform and Control Act.
Signature of Applicant*
Date*
MM slash DD slash YYYY

Online Application

Step 1 of 10

Personal Information

Position Applied for and/or Area of Interest

References

Ohio Civil Service Application

Preferences

Education

Employment History

Employer #1

Employer #2

Employer #3

Employer #4

Certificates & Licenses

Skills

Certification

State of Ohio Equal Employment Opportunity

Contact Shelby County Board of DD