BOYD'S KINSMAN HOME, INC.

APPLICATION FOR EMPLOYMENT

Boyd's Kinsman Home does not discriminate in the provision of services or employment because of race, color, national origin, religion, age, sex or handicap.

PERSONAL INFORMATION

EMPLOYMENT DESIRED

EDUCATION

Type of School Name/City # of years Graduate?
High School/GED
College/University
Graduate/Professional Trade/Technical
Please explain why you are applying for this position. List any special skills or experience relative to the position for which you are applying.

PRESENT & FORMER EMPLOYERS

(Required pursuant to MR/DD rule 5123:2-3-06)
Month & Year Employer – address & phone Position/Duties Salary Reason for Leaving

CHARACTER REFERENCE

Please list one person unrelated to you whom you have known for at least one year
Do you have any physical, mental or medical disability which you believe may limit or interfere with
your ability to perform the job for which you are applying?
            If yes, please explain disability and accommodations needed:
Have you ever been convicted of, or pleaded guilty to, a crime?
If your application is considered for employment, you will be required to undergo a criminal background check.
            If yes, please explain the circumstances below:
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I declare that the above information and statements are true and that I have not knowingly withheld any facts that would, if disclosed, affect my application unfavorably. I understand that if Boyd's Kinsman Home discovers significant inaccuracies or omissions in the above information and statements, I may be denied employment or, if already employed, I may be discharged. By signing this application I understand that Boyd's Kinsman Home will be contacting my present and/or past employers and character reference should I be considered for employment.

**Please let us know what hours you would be available to work each day of the week.**
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Comments and/or Other Explanations:
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Boyd's Kinsman Home, Inc.
Release of Information for References

I, , hereby authorize BOYD'S KINSMAN HOME to make any
investigation of my prior employment or educational history. This information will assist them in their
assessment of my qualifications. I also give permission to BOYD'S KINSMAN HOME to contact the
persons I named in order to complete a personal reference check.

I hereby authorize my present and past employers and schools that I have attended to release any and all employment information and any other confidential information that BOYD'S KINSMAN HOME may request.

I understand that any information released by my prior employer or school will be held in strictest confidence, that it will be viewed only by those involved in the hiring decision, and that neither I nor anyone else not so involved will have the right to see the information. I specifically indemnify BOYD'S KINSMAN HOME and the person(s) contacted from any and all claims of libel or slander arising out of the completion of this reference check.

I have carefully read and reviewed all the provisions above and have voluntarily agreed to sign this authorization.

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PLEASE RETURN COMPLETED APPLICATION TO BOYD'S KINSMAN HOME

in person, mail, e-mail, or fax:
PO Box 315, 7929 St Rt 5, Kinsman, OH 44428
Fax : 330-876-8804
E-mail to : bkh@bkhohio.com
Or Call with questions: 330-876-5581