Stow, Ohio | 330-686-7100

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If there is change in your availability, it is your responsibility to complete and submit a new “Availability Record” (at left) for our files, indicating your current availability. Such record will then be effective for any future employment considerations.

I understand that there may be occasions when this facility will require me to temporarily work shifts othe than the particular one for which I am applying and agree to such scheduling changes as directed by my department head, manager or administrator of this corporation.

Employment History

Please provide the following requested information regarding your employment history: Include military service assignments and volunteer activities. You may exclude organization names that include race, color, religion, gender, national origin, ancestry, age, disability or other protected status.

If you do not have a work history, please write N/A for the below fields.





Please list three professional references including at least two direct Supervisors:

3701-60-06 Criminal records check: disqualifying offenses.

3701-60-06 Criminal records check: disqualifying offenses.

(A) Except as provided in rule 3701-60-07 of the Administrative Code, no employer shall employ or continue to employ a person in a position that involves providing direct care to an individual if the person has been convicted of:

(1) A violation of any of the following sections of the Revised Code:

(a) 959.13 (cruelty to animals);

(b) 959.131 (prohibitions concerning companion animals);

(c) 2903.01 (aggravated murder);

(d) 2903.02(murder) ;

(e) 2903.03 (voluntary manslaughter);

(f) 2903.04 (involuntary manslaughter);

(g) 2903.041 (reckless homicide);

(h) 2903.11 (felonious assault);

(i) 2903.12 (aggravated assault);

(j) 2903.13(assault) ;

(k) 2903.15 (permitting child abuse);

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

(m) 2903.21 (aggravated menacing);

(n) 2903.211 (menacing by stalking);

(o) 2903.22(menacing) ;

(p) 2903.34 (patient abuse and neglect);

(q) 2903.341 (patient endangerment);

(r) 2905.01(kidnapping) ;

(s) 2905.02(abduction) ;

(t) 2905.04 (child stealing, as it existed before July 1, 1996);

(u) 2905.05 (criminal child enticement);

(v) 2905.11(extortion) ;

(w) 2905.12(coercion) ;

(x) 2905.32 (trafficking in persons);

(y) 905.33 (unlawful conduct with respect to documents);

(z) 2907.02(rape) ;

(aa) 2907.03 (sexual battery);

(bb) 2907.04 (unlawful sexual conduct with a minor, formerly corruption of a minor);

(cc) 2907.05 (gross sexual imposition);

(dd) 2907.06 (sexual imposition);

(ee) 2907.07(importuning) ;

(ff) 2907.08(voyeurism) ;

(gg) 2907.09 (public indecency);

(hh) 2907.12 (felonious sexual penetration, as it existed before July 1, 1996);

(ii) 2907.21 (compelling prostitution);

(jj) 2907.22 (promoting prostitution);

(kk) 2907.23 (enticement or solicitation to patronize a prostitute; procurement of a prostitute for another);

(ll) 2907.24 (soliciting after positive HIV test);

(mm) 2907.25(prostitution) ;

(nn) 2907.31 (disseminating matter harmful to juveniles);

(oo) 2907.32 (pandering obscenity);

(pp) 2907.321 (pandering obscenity involving a minor);

(qq) 2907.322 (pandering sexually oriented matter involving a minor);

(rr) 2907.323 (illegal use of a minor in nudity-oriented material or performance);

(ss) 2907.33 (deception to obtain matter harmless to juveniles);

(tt) 2909.02 (aggravated arson);

(uu) 2909.03(arson) ;

(vv) 2909.04 (disrupting public services);

(ww) 2909.22 (soliciting or providing support for act of terrorism);

(xx) 2909.23 (making terroristic threat);

(yy) 2909.24(terrorism) ;

(zz) 2911.01 (aggravated robbery);

(aaa) 2911.02(robbery) ;

(bbb) 2911.11 (aggravated burglary);

(ccc) 2911.12(burglary) ;

(ddd) 2911.13 (breaking and entering);

(eee) 2913.02(theft) ;

(fff) 2913.03 (unauthorized use of a vehicle);

(ggg) 2913.04 (unauthorized use of property, computer, cable, or telecommunication property);

(hhh) 2913.05 (telecommunications fraud);

(iii) 2913.11 (passing bad checks);

(jjj) 2913.21 (misuse of credit cards);

(kkk) 2913.31 (forging identification cards);

(lll) 2913.32 (criminal simulation);

(mmm) 2913.40 (medicaid fraud);

(nnn) 2913.41 (defrauding a rental agency or hostelry);

(ooo) 2913.42 (tampering with records);

(ppp) 2913.43 (securing writings by deception);

(qqq) 2913.44 (personating an officer);

(rrr) 2913.441 (unlawful display of law enforcement emblem);

(sss) 2913.45 (defrauding creditors);

(ttt) 2913.46 (illegal use of SNAP or WIC program benefits);

(uuu) 2913.47 (insurance fraud);

(vvv) 2913.48 (workers' compensation fraud);

(www) 2913.49 (identify fraud);

(xxx) 2913.51 (receiving stolen property);

(yyy) 2917.01 (inciting to violence);

(zzz) 2917.02 (aggravated riot);

(aaaa) 2917.03(riot) ;

(bbbb) 2917.31 (inducing panic);

(cccc) 2919.12 (unlawful abortion);

(dddd) 2919.121 (unlawful abortion upon minor);

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

(ffff) 2919.22 (endangering children);

(gggg) 2919.23 (interference with custody);

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

(iiii) 2919.25 (domestic violence);

(jjjj) 2921.03(intimidation) ;

(kkkk) 2921.11(perjury) ;

(llll) 2921.12 (tampering with evidence);

(mmmm) 2921.13 (falsification - in theft offense- to purchase firearm);

(nnnn) 2921.21 (compunding a crime);

(oooo) 2921.24 (disclosure of confidential information);

(pppp) 2921.32 (obstructing justice);

(qqqq) 2921.321 (assaulting or harassing a police dog, horse, or service animal);

(rrrr) 2921.34(escape) ;

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

(tttt) 2921.36 (illegal conveyance of weapons, drugs or other prohibited items onto grounds of detention facility or institution);

(uuuu) 2921.51 (impersonation of peace officer);

(vvvv) 2923.12 (carrying concealed weapon);

(wwww) 2923.122 (illegal conveyance or possession of deadly weapon or dangerous ordinance in a school safety zone, illegal possession of an object indistinguishable from a firearm in a school safety zone);

(xxxx) 2923.123 (illegal conveyance, possession, or control of deadly weapon or ordnance into a courthouse);

(yyyy) 2923.13 (having weapons while under disability);

(zzzz) 2923.161 (improperly discharging a firearm at or into a habitation or school);

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

(bbbbb) 2923.21 (improperly furnishing firearms to minor);

(ccccc) 2923.32 (engaging in a pattern of corrupt activity);

(ddddd) 2923.42 (participating in criminal gang);

(eeeee) 2925.02 (corrupting another with drugs);

(fffff) 2925.03 (trafficking in drugs);

(ggggg) 2925.04 (illegal manufacture of drugs or cultivation of marijuana);

(hhhhh) 2925.041 (illegal assembly or possession of chemicals for the manufacture of drugs);

(iiiii) 2925.05 (funding of drug or marijuana trafficking);

(jjjjj) 2925.06 (illegal administration or distribution of anabolic steroids);

(kkkkk) 2925.09 (illegal administration, dispensing, distribution, manufacture, possession, selling, or using of any dangerous veterinary drug);

(lllll) 2925.11 (possession of drugs);

(mmmmm) 2925.13 (permitting drug abuse);

(nnnnn) 2925.14 (illegal use, possession, dealing, selling, or advertising of drug paraphernalia);

(ooooo) 2925.141 (illegal use or possession of marihuana drug paraphernalia);

(ppppp) 2925.22 (deception to obtain dangerous drugs);

(qqqqq) 2925.23 (illegal processing of drug documents);

(rrrrr) 2925.24 (tampering with drugs);

(sssss) 2925.36 (dispensing drug samples);

(ttttt) 2925.55 (unlawful purchase of pseudoephedrine product);

(uuuuu) 2925.56 (unlawful sale of pseudoephedrine product);

(vvvvv) 2927.12 (ethnic intimidation);

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

(2) If related to an offense listed under paragraph (A)(1) of this rule, 2923.01(conspiracy) , 2923.02(attempt) , or 2923.03(complicity) ; or

(3) 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 (A)(1)(a) to (A)(1)(wwww) of this rule.

Replaces: 3701-60-06

Effective: 01/01/2013
R.C. 119.032 review dates: 12/01/2017
Promulgated Under: 119.03
Statutory Authority: 3701.881
Rule Amplifies: 3701.881
Prior Effective Dates: 7/24/1997 (Emer.), 10/24/97, 11/12/07


NOTICE: In compliance with the FAIR CREDIT REPORTING ACT, I have been advised that a credit report may be ordered to check my credit history, bankruptcies, suits and judgments. If accepted for employment, I agree to submit myself for examination by a physician or physicians of the Company’s selection as often as may be requested. I certify that the information contained in this application is correct to the best of my knowledge and understand that deliberate falsification of this information is grounds for dismissal in accordance with Company policy. I authorize all persons, companies, schools, credit bureaus, and government agencies to supply any information concerning my background, and release all parties from all liability for any damage that may result from furnishing same to you. I also release the Company and its agent, Accurate Background Checks, Inc. from all liability from damages arising from this research of my background. I understand that agreement to resolve all disputes or claims related to my employment though the Facility’s Dispute Resolution Procedure (“DRP”) is a condition of employment at Stow-Glen Retirement Village. By signing and submitting this application for employment, I acknowledge and agree in the event of my hire to resolve all disputes or claims relating to my employment including legal claims of unlawful employment discrimination or wrongful discharge, but excluding claims for workers’ compensation benefits through DRP. I further agree to waive any right to seek resolution of such disputes or claims in any other forum.

Note: Applications are considered current for 60 days.


This is to inform you that Stow-Glen, Inc. conducts testing to identify job applicants and current employees who may be abusing drugs and/or alcohol.

You have the right to refuse to undergo testing. However, the consequences of refusal to undergo testing or a refusal to cooperate in testing by an applicant will result in the termination of the pre-employment selection process, and the consequences of refusal to undergo testing or a refusal to cooperate in the testing by an employee will result in disciplinary action up to and including discharge.

An applicant who tests positive for a controlled substance, without a valid prescription for that substance which is disclosed to the testing entity, will not be hired.

Any employee, who tests positive for a controlled substance, without a valid prescription for that substance which is disclosed the testing entity, will be subject to disciplinary action up to and including discharge.

Remaining drug-and/or alcohol-free and participation in Stow-Glen’s drug and alcohol testing program is a condition of continued employment.


U.S. Equal Employment Opportunity/Affirmative Action Information
Individuals seeking employment are considered without regards to race, color, religion, national origin, age, sex, marital status, ancestry, physical or mental disability, veteran status, or sexual orientation. You are being given the opportunity to provide the following information in order to help us comply with federal and state Equal Employment Opportunity/Affirmative Action record keeping, reporting, and other legal requirements.

Please Note: Completion of this form is voluntary
Completion of the form is entirely voluntary. Whatever your decision, it will not be considered in the hiring process or thereafter. Any information that you do provide will be recorded and maintained in a confidential file.



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