“An Equal Opportunity Employer”
Applicants are considered for all positions without regard to race, color,
sex, national origin, age, marital status or veteran status, or the
presence of non-job-related medical condition or handicap.”
Employment Application
APPLICANT INFORMATION
Last Name
First
Street Address
City
Home Phone:
Cell Phone:
Date Available
Social Security No.
Position Applied for
M.I.
Date
Apartment/Unit #
Zip
State
Email Address:
DL or ID #
Are you a citizen of the United States
YES
Are you at least 18 years of age?
YES
NO
Availability?
Have you ever worked for this company
YES
NO
If so, when?
Have you ever been convicted of any
crime?
Do you have valid driver’s license?
YES
NO
If yes, explain
YES
NO
If no, explain
EDUCATION
High School
From
To
Did you graduate?
YES
NO
Degree
YES
NO
Degree
YES
NO
Degree
Address
To
Other
From
If no, are you authorized to work in the U.S.?
Address
College
From
NO
Did you graduate?
Address
To
Did you graduate?
REFERENCES
Please list two professional references
Full Name
Relationship
Company
Phone
(
)
Address
Relationship
Full Name
Company
Phone
(
)
(
)
Address
PREVIOUS EMPLOYMENT
Company
Phone
Address
Supervisor
Job Title
Starting Salary
Employment Application-PEAK Updated January 2013
$
Ending Salary $
1
Responsibilities
From
To
Reason for Leaving
May we contact your previous supervisor for a
reference?
YES
NO
Company
Phone
Address
Supervisor
Job Title
Starting Salary
(
)
$
Ending Salary $
Responsibilities
From
To
Reason for Leaving
May we contact your previous supervisor for a
reference?
YES
Company
Phone
Address
Supervisor
Job Title
Starting Salary
Responsibilities
From
To
May we contact your previous supervisor for a
reference?
NO
(
)
$
Ending Salary $
Reason for Leaving
YES
NO
POLICY
Have you ever been discharged from a facility for abuse or neglect?
YES
NO
After reviewing the job description, are you able to perform the essential functions of the job?
If yes, explain
YES
It is Peak Policy to pay wages through direct deposit. Are you able to accommodate this policy?
Have you been an Ohio resident for the past 5 years?
YES
YES
NO
NO
NO
SKILLS
Please use this space to list any special skills, work experience, certifications/licenses, etc. that may relate to the position
for which you are applying:
NOTICE
This is to inform you that as part of our procedure for processing your employment application, we may obtain a
consumer report containing financial and other information about you. Will not obtain such a report without your signed
authorization.
We comply with the Fair Credit Reporting Act, which provides consumers with rights regarding consumer reports and
which places specific obligations on employers using credit reports.
Employment Application-PEAK Updated January 2013
2
BACKGROUND INVESTIGATION AUTHORIZATION AND DISCLOSURE FORM
In connection with my application for employment, I authorize PEAK, Inc. to order a consumer report to adequately investigate my
background which may include my
o Academic record
o Criminal record
o Employment record
o Military service record
o Financial and Credit Information
o Reputation and character record
I understand that information obtained from this background investigation may constitute a basis for denial of my employment. I also
understand that any information obtained from this background investigation will be used solely for the purpose it was intended and will
not be disseminated outside P.E.A.K., Inc.
I hereby acknowledge that I have read the above disclosure statement and understand it.
I authorize, without reservation, any party or agency contacted by this employer or its agent to furnish the above mentioned
information:
____________________________________________________ ____________________________
Signature (must be signed)
Date
___________________________
Social Security Number
CRIMINAL RECORDS CHECK
P.E.A.K., Inc., is required to obtain a criminal record check for individuals who are hired to comply with Ohio Licensure requirements. A
criminal records check will be ordered from the Bureau of Criminal Investigation (BCI) only if an applicant for employment is under final
consideration for employment.
As an applicant for employment at P.E.A.K., Inc., I understand that a set of fingerprint impressions will be taken for BCI and will also be
taken for the Federal Bureau of Investigation (FBI) if I have not lived in the state of Ohio for the last five consecutive years in order to
process the required criminal records check. I understand further that if I am hired by P.E.A.K., Inc., my employment will be conditional
pending receipt of the results of the criminal records check. Lastly, I understand that if, while I am employed by P.E.A.K., Inc., I am
convicted of an offense that would have precluded my being employed by P.E.A.K., Inc., P.E.A.K., Inc., will terminate my employment.
____________________________________________________
Signature (must be signed)
____________________________
Date
MOTOR VEHICLE REPORT AUTHORIZATION
The undersigned, as an employee or prospective employee of P.E.A.K., Inc., does hereby authorize P.E.A.K., Inc., to obtain a copy of
my Motor Vehicle Report. The Motor Vehicle Report will be used as determining driving eligibility by the insuring company of P.E.A.K.,
Inc.
I also understand that, as an employee of P.E.A.K., Inc., my Motor Vehicle Report may be reviewed periodically over the course of my
employment. I understand that this information is privileged and confidential and agree to its release.
____________________________________________________
Signature (must be signed)
____________________________
Date
DISCLAIMER AND CERTIFICATION AGREEMENT SIGNATURE
I certify that my answers are true and complete to the best of my knowledge.
I authorize P.E.A.K., Inc. to verify any information I have provided and I further authorize any of the named schools, companies or
persons listed above to provide any information about me contained in their records and release them from liability for such disclosure.
My signature below hereby authorizes disclosure of information and releases P.E.A.K., Inc., its offices and employees from liability for
such disclosures. I understand that P.E.A.K., Inc. is an, at will employer, and either party may terminate employment at any time.
If this application leads to employment, I understand that false or misleading information in my application or interview may result in my
release.
____________________________________________________ ____________________________
Signature (must be signed)
Date
Employment Application-PEAK Updated January 2013
3
Employment Application-PEAK Updated January 2013
4
Criminal Notification Statement
2903.34
2903.341
Tier 1 Disqualifying Offenses (permanent
exclusion)
Aggravated murder
Murder
Voluntary manslaughter
Felonious assault
Permitting child abuse
Failing to provide for functionally impaired
person
Patient abuse; neglect
Patient endangerment
2905.01
2905.02
2905.32
2905.33
2907.02
Kidnapping
Abduction
Human trafficking
Unlawful conduct with respect to documents
Rape
2909.02
2909.3
2911.01
2911.11
2913.46
2907.03
2907.04
2913.48
2913.49
2907.05
2907.06
Sexual battery
Unlawful sexual conduct with a minor,
formerly corruption of a minor
Gross sexual imposition
Sexual imposition
2907.07
Importuning
2923.02
2907.08
Voyeurism
2923.03
2907.12
2907.31
Felonious sexual penetration
Dissemination matter harmful to juveniles
2923.12
2923.122
2907.32
Pandering obscenity
2923.123
2907.321
2907.322
Pandering obscenity involving a minor
Pandering sexually oriented matter involving a
minor
Illegal use of a minor in nudity- oriented material
or performance
Soliciting/providing support for act of terrorism
Making terrorist threat
terrorism
Medicaid fraud
Conspiracy - when the underlying offense is any
of the offenses or violations on this list
Attempt - when the underlying offense is any of
the offenses or violations on this list
Complicity - when the underlying offense is any
of the offenses or violations on this list
A conviction related to fraud, theft,
embezzlement, breach of fiduciary responsibility,
or other financial misconduct involving a federal
or state-funded program, excluding the
disqualifying offenses set forth in section
2913.46 of the Revised Code (illegal use of
supplemental nutrition assistance program
[SNAP] or women, infants, and children [WIC]
program benefits).
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 on this list.
2923.13
2923.161
Aggravated riot
Conspiracy when the underlying offense is any of the offenses or
violations on this list.
Attempt - when the underlying offense is any of the offenses or
violations on this list
Complicity - when the underlying offense is any of the offenses or
violations on this list
Carrying concealed weapon
Illegal conveyance or possession of deadly weapon or dangerous
ordnance in a school safety zone, illegal possession of an object
indistinguishable from a firearm in a school safety zone
Illegal conveyance , possession, or control of a deadly weapon or
dangerous ordnance into courthouse
Having weapons while under disability
Improperly discharging a firearm at or into a habitation or school
2923.162
Discharge of firearm on or near prohibited premises
2923.21
2923.32
2923.42
2925.02
2925.03
Improperly furnishing firearms to minor
Engaging in pattern of corrupt activity
Participating in criminal gang
Corrupting another with drugs
Trafficking in drugs
2925.04
Illegal manufacture of drugs or cultivation of marihuana
2925.041
Illegal assembly or possession of chemicals for the manufacture of
drugs
Placing harmful objects in food or confection
2903.01
2903.02
2903.03
2903.11
2903.15
2903.16
2907.323
2909.22
2909.23
2909.24
2913.4
2923.01
2923.02
2923.03
Employment Application-PEAK Updated January 2013
Tier 2 Disqualifying Offenses (10-Year Exclusion)
2903.04
2903.041
2905.04
2905.05
2905.11
2907.21
Involuntary manslaughter
Reckless homicide
Child stealing – as it existed prior to July 1, 1996
Criminal child enticement
extortion
Compelling prostitution
2907.22
2907.23
Promoting prostitution
Enticement or solicitation to patronize a prostitute, procurement of a
prostitute for another
Aggravated arson
Arson
Aggravated robbery
Aggravated burglary
Illegal use of supplemental nutrition assistance program [SNAP] or
women, infants, and children [WIC] program benefits
Workers’ compensation fraud
Identity fraud
2917.02
2923.01
3716.11
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 on this list.
5
959.13
959.131
2903.12
2903.21
2903.211
2905.12
2909.4
2911.02
2911.12
2913.47
2917.01
2917.03
2917.31
2919.22
2919.25
2921.03
2921.11
2921.13
2921.34
2921.35
2921.36
2923.01
2923.02
2923.03
2925.05
2925.06
2925.24
2927.12
Tier 3 Disqualifying Offenses (Seven-Year
Exclusion)
Cruelty to animals
Prohibitions concerning companion animals
Aggravated assault
Aggravated menacing
Menacing by stalking
Coercion
Disrupting public service
Robbery
Burglary
Insurance fraud
Inciting to violence
Riot
Inducing panic
Endangering children
Domestic violence
Intimidation
Perjury
Falsification, falsification in theft offense,
falsification to purchase firearm, or falsification to
obtain a concealed handgun license
Escape
Aiding escape or resistance to lawful authority
Illegal conveyance of weapons, drugs or other
prohibited items onto grounds of detention
facility or institution
Conspiracy - when the underlying offense is any
of the offenses or violations on this list
Attempt - when the underlying offense is any of
the offenses or violations on this list
Complicity - when the underlying offense is any
of the offenses or violations on this list
Funding of drug or marihuana trafficking
Illegal administration or distribution of anabolic
steroids
Tampering with drugs
Ethnic intimidation
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 on this list.
Tier 4 Disqualifying Offenses (Five-Year Exclusion):
2903.13
2903.22
2907.09
2907.24
2907.25
2907.33
2911.13
2913.02
2913.03
2913.04
2913.05
2913.11
2913.21
2913.31
2913.32
2913.41
2913.42
2913.43
Assault
Menacing
Public indecency
Soliciting after positive human immunodeficiency virus test
Prostitution
Deception to obtain matter harmful to juveniles
Breaking and entering
Theft
Unauthorized use of a vehicle
Unauthorized use of property, computer, cable, or telecommunication
property
Telecommunications fraud
Passing bad checks
Misuse of credit cards
Forgery, forging identification cards
Criminal simulation
Defrauding a rental agency or hostelry
Tampering with records
Securing writings by deception
2913.44
2913.441
2913.45
Personating an officer
Unlawful display of law enforcement emblem
Defrauding creditors
2913.51
Receiving stolen property
2919.12
Unlawful abortion
2919.121
Unlawful abortion upon minor
2919.123
2919.23
Unlawful distribution of an abortion-inducing drug
Interference with custody
2919.24
2921.12
2921.21
Contributing to unruliness or delinquency of child
Tampering with evidence
Compounding a crime
2921.24
2921.32
2921.321
2921.51
2923.01
Disclosure of confidential information
Obstructing justice
Assaulting/harassing police dog or horse/service animal
Impersonation of a peace officer
Conspiracy - when the underlying offense is any of the offenses or
violations on this list
Attempt - when the underlying offense is any of the offenses or
violations on this list
Complicity - when the underlying offense is any of the offenses or
violations on this list
Illegal administration, dispensing, distribution, manufacture, possession,
selling or using any dangerous veterinary drug
Drug possession other than a minor drug possession offense
Permitting drug abuse
Deception to obtain dangerous drugs
Illegal processing of drug documents
Illegal dispensing of drug samples
Unlawful purchase of pseudoephedrine product
Unlawful sale of pseudoephedrine product
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 on this list.
2923.02
2923.03
2925.09
2925.11
2925.13
2925.22
2925.23
2925.36
2925.55
2925.56
P.E.A.K., Inc., will not employ any applicant with Tier 1 disqualifying offenses per rule. All other offenses in Tier
1-4 will per rule and based upon discretion of agency administration.
Employment Application-PEAK Updated January 2013
6
Name: (print) _____________________________________________
Date: __________________

I certify that I have reviewed the list of criminal codes in Tier 1-4 as presented. I also certify that I have not been
convicted of or pleaded guilty of the listed crimes.

I further agree to notify the employer within fourteen calendar days if, while employed by the provider, I am ever
formally charged with, convicted of, or pleads guilty to any of the offenses listed or described in the list of nonqualifying criminal codes. My signature attests that I have been informed that by signing this document my failure
to report formal charges, a conviction, or guilty plea may result in being dismissed from employment.

I certify that I have been a State of Ohio resident for the last 5 years.

I give P.E.A.K., Inc. permission to complete all background checks which may include but not limited to:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Abuser Registry
Sex offender Database
United States general services administration system (Inspector General & SAM)
Database of incarcerated and supervised offenders
DODD Abuser Registry
DOH Nurse Aide Registry
References
Drug Testing
Ohio BMV
BCI
FBI (if I have not lived in Ohio for the last 5 years)
If your name appears negatively on any of the above checks 1-7, our agency is prohibited from hire; therefore, we
will not employ no continue to employ if an applicant’s nor employee’s name appears on any of the above
databases.
Please check each box, if you have read and understand information provided.
______________________________________________
Name (Signature)
Employment Application-PEAK Updated January 2013
_________________________
date signed
7
CONSENT & RELEASE
(Random Drug Free Workplace Testing)
_________________________________________
Name (print)
_______/______/______
Date – Month/Day/Year
If hired by PEAK, INC.,
_______
I agree to provide a breath sample for the purpose of drug testing and analysis. I also grant permission to
have the results of such testing released to my employer.
_______
I agree to provide a urine sample for the purpose of drug testing and analysis. I also grant permission to
have the results of such testing released to my employer.
Failure to report and provide a breath and urine specimen or failure to cooperate in the testing process will result
in your termination for insubordination.
____________________________________
Signature
____________________________________
Witness
OHIO BUREAU OF WORKERS’ COMPENATION
REQUIRED POSTING
Effective October 13, 2004. Section 4123.54 of the Ohio Revised Code requires
notice of rebuttable presumption. Rebuttable presumption means that an employee
may dispute or prove untrue the presumption (or belief) that alcohol or a controlled
substance not prescribed by the employee’s physician is the proximate cause (main
reason) of the work-related injury.
The burden of proof is on the employee to prove that the presence of alcohol or a
controlled substance was not the proximate cause of the work-related injury. An
employee who tests positive or refuses to submit to chemical testing may be
disqualified for compensation and benefits under the Workers’ Compensation Act.
THIS LANGUAGE MUST BE POSTED WITH THE CERTIFICATE OF COVERAGE
Employment Application-PEAK Updated January 2013
8
P.E.A.K., Inc.
Providing Excellent Adult Kare
P.E.A.K., Inc. Employee Training and Screening Deduction Authorization
I understand, as a P.E.A.K., Inc. employee in orientation status (as defined in Policy and Procedures
2/03), that the following costs associated with employee training and/or screening shall be deducted
from my final paycheck if I decide to voluntarily terminate employment within the first six (6) months.
I also understand that these costs shall be deducted from my final paycheck if I am in violation of
P.E.A.K., Inc. policies and procedures resulting in my termination of employment within the first six (6)
months.
Medication Administration Training
(Certification I)
G-Tube Procedures (Certification II)
Insulin Procedure (Certification III)
Therapeutic
Assault
Prevention
Systems (TAPS)
CPR/First Aid Training
Hepatitis B Vaccination
TB Screen
BCI Fingerprint Check
FBI Check
New Employee Training/Orientation
Class
$100.00
$50.00
$50.00
$50.00
$50.00
$50.00
$5.00
$25.00
$35.00
$50.00
All final paycheck deductions for trainings and screenings will not exceed a total amount where all
hours worked in the final pay periods decrease an employee’s wages below minimum wage in
accordance with the federal Fair Labor Standards Act.
Employee Printed Name ____________________________________________
Employee Signature _________________________________ Date __________
Witness _________________________________________________________
Employment Application-PEAK Updated January 2013
9