372 E. Center Street P.O. Box 779 Marion, Ohio 43301-0779 Phone (740) 387-1039 Fax (740) 387-8006	Phone: (877) 241-3427 Toll Free Marion Phone: (800) 854-4020 Toll Free Galion Phone: (866) 546-4314 Toll Free Mt. Gilead Phone: (866) 589-4315 Toll Free Mansfield
Samuel J. Buehrer President	Andrew Joseph Devany Executive Director

Instructions Employment Desired Personal Information Previous Employment Education Background Languages References Professional Association Accomplishments Additional Info Affirmative Action Info Affidavit

PLEASE READ THE FOLLOWING BEFORE COMPLETING OUR APPLICATION FOR EMPLOYMENT FORM. There is no guarantee of a job offer or job interview in completing our application form. Your application form will be considered with others who have submitted applications and decisions about interviews will be based on this comparison. Our application form must be completely filled out in order for it to be considered for employment. DO NOT use “see resume” as an answer. If the information provided on our application cannot be satisfactorily verified by employment reference checks your application could be considered as incomplete. Applications are filed according to job title. Be as specific as possible in stating the job applying for: ANY position is not an acceptable response on our application form. Read a copy of the job description before filling out our application form. Due to the large number of applications we receive and the competitive nature of our employment process specific reasons for employment will not be released. In completing our application form you will be subject to the following checks: EMPLOYMENT REFERENCE CHECK FROM FORMER EMPLOYERS CRIMINAL RECORD CHECK DRUG SCREEN I have read the above statements. I hereby acknowledge and understand that Ohio Heartland Community Action Commission may conduct background checks with the Bureau of Criminal Investigation and that such checks may involve fingerprinting.