Employment Application Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. – Step 1 of 8EQUAL EMPLOYMENT/AFFIRMATIVE ACTION POLICY It is the policy of Legacy IIl, Inc. to provide equal employment opportunities to all qualified employees and applicants regardless of race, color, religion, sex, national origin, age, ancestry, disability, and status as a special disabled veteran or veteran of the Vietnam era and to comply with applicable federal, state, and local laws and regulations prohibiting discrimination in employment practices. To be considered for employment, please complete the entire application.Position Applying For *Name *FirstLastEmail *PhoneAddressAddress Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeAre you at least 18 years old?YesNoHave you ever been employed by Legacy III? (copy)YesNoIf you are hired, can you provide documentation that you are a United States citizen or an alien who is authorized to work in the United States?YesNoFederal law requires employers to verify this documentation at the time of employment and prohibits the employment of individuals who cannot provide appropriate documentation. NextWORK EXPERIENCE Company NameAddressName of SupervisorPhoneJob TitleStart DateJob DescriptionEnd DateReason for LeavingCurrent Salary Add More Experience Remove If you are presently employed, may we contact your employer:YesNoIf your current or previous employers know you by another name, please state this name:PreviousNextEDUCATION List High School, Business or Trade School or College School (Name)AddressDates AttendedGPADid You Graduate?YesNoIf you did not graduate, list the number of hours completed. Add More Schools Remove If you are currently enrolled in school, when will you graduate (month/year)List any professional licenses or certificates you hold which are relevant to the position for which you are applying. Indicate state and certificate number (if applicable).List any additional education, training, skills, or experience which are relevant to the position for which you are applying.PreviousNext (month/year) or nature AUTOMOBILE INSURABILITY THROUGH AGENCY CARRIER One of the job requirements for employment at Legacy IlI is possession of a valid Ohio driver’s license and insurability through the agency’s insurance carrier, in addition to your own personal insurance. Do you have a valid Ohio driver's license?YesNoDo you have auto insurance?YesNoPlease list auto insurance carrier.Please answer the questions below: Have you had any traffic violations within the past five years?YesNoIf yes, please explain when, the type of violation and the outcome (i.e., did you receive a ticket, if there was an accident, vere you cited, etc.).REQUIRED: All applicants must complete and sign the following Driving Record Permission Slip which will be submitted to Legacy Ill’s insurance carrier to verify insurability. PreviousNextDRIVING RECORD PERMISSION SLIP Herewith is my signature allowing access to my driving record(s). Date of applicationMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Name *FirstLastState LicensedExpiration DateMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Date of BirthMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Applicant Signature (Use your computer mouse, touchpad, or fingertip on your phone) Clear Signature PreviousNextMILITARY SERVICE Are you currently enlisted in the U.S. military (active duty or reserves)?YesNoBranch of ServiceMilitary Occupational Specialty (MOS)Date of EnlistmentMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Date of DischargeMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Describe your duties and training which are relevant to the job for which you are applying.Have you ever been convicted of a crime?YesNoIf yes, describe and give dates of convictions. A conviction record will not necessarily bar you from employment. Factors such as the number, recentness, seriousness, nature of the violation, and rehabilitation will be taken into account.PreviousNextAPPLICANT’S STATEMENT OF AGREEMENT Read the following carefully before signing this employment application. I certify that the information given in this employment application is accurate and complete to the best of my knowledge. I understand that any misrepresentation, falsification, and deliberate omission of information on this application and in the employment process shall result in my disqualification from further consideration for employment or shall result in the termination of my employment with the Agency. I authorize Legacy IlI, Inc. to obtain all available information from past employers, my present employer (unless specifically requested otherwise), and other applicable sources. I understand that Legacy Il may obtain or have prepared an investigative report on me as an applicant for employment. Further, I understand that, upon written request, information as to the nature and scope of the inquiry will be provided. I understand that if a job is offered to me and I accept it, my employment will be contingent upon satisfactorily passing a drug screen. If selected for employment, I agree to submit to a physical examination at any time at the discretion of the agency. I shall be governed by the report of the examining physician and that determination of Legacy lIl regarding my ability to perform the duties to which I am assigned at that time or any other duties that I may be capable of performing. I also understand that I will be required to have a background check performed for the last five (5) years through the Akron Police Department. I understand that if I am offered a job and I accept if, that I, like all Legacy IlI employees, am an employee-at-will. As such, I may terminate my employment with Legacy IlI at any time, with or without notice, and for any or no reason, and likewise may be terminated from employment by Legacy IlI in the same manner, except as where otherwise prohibited by law. I further understand that no agency policies or benefits should be construed as a contract, promise, or guarantee of employment of any kind and that only the Chief Executive Officer or Board of Trustees has the authority to authorize any agreement contrary to the foregoing, and then only in writing.I have read and fully understand the contents of this agreement. Applicant Signature (Use your computer mouse, touchpad, or fingertip on your phone) Clear Signature DateMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Upload Cover Letter, Resume, & References Click or drag files to this area to upload. You can upload up to 3 files. PreviousNextCustom Captcha * = PreviousSubmit Your Application
