Employment Application

POSITION

Position Applying For (required)

Available Start Date (required)

Today's Date (required)

PERSONAL INFORMATION

Name (First, Last) (required)

Address (required)

City, State, Zip (required)

Phone Number (required)

Email Address

Are you able, at the time of employment to submit verfication of your legal right to work in the United States? (required)

Yes

EDUCATION

List any colleges, military, trade, business, or other schools attended.

Do you have a high school diploma or GED Certificate? (required)

Yes

School Name

Location

Diploma/Degree

Major/Minor

Did you graduate? (Include date)

Additional Education

CERTIFICATES & LICENSES

List professional license, registration, or certificate required or preferred for position.

Type

Issuing Agency

Date Issued

Date Expires

Additional Certificates & LIcenses

EMPLOYMENT HISTORY

The information in this section will be used to determine if you meet the minimum qualifications as outlined in the job announcement. Clearly describe all your duties, starting with your most recent job. Resumes will be accepted only if required on the job announcement and will not be accepted in place of a completed application. If you need additional space, use the box at the bottom of this section.

Employer (1)

Job Title

Dates Employed (from-to)

Address

City, State, Zip

Supervisor Name

Phone Number

May we contact? (required)

Yes

Reason for leaving

Employer (2)

Job Title

Dates Employed (from-to)

Address

City, State, Zip

Supervisor Name

Phone Number

May we contact?

Yes

Reason for leaving

Employer (3)

Job Title

Dates Employed (from-to)

Address

City, State, Zip

Supervisor Name

Phone Number

May we contact?

Yes

No Explanation:

Reason for leaving

Additional Employment History

REFERENCES

Name (1) (required)

Title

Company

Relationship to you (required)

Phone (required)

Name (2) (required)

Title

Company

Relationship to you (required)

Phone (required)

Name (3) (required)

Title

Company

Relationship to you (required)

Phone (required)

Additional References

CERTIFICATION & SIGNATURE

I hereby certify that all statements made in this application are true, and I agree and understand that any statement that is false, fraudulent, or misleading in this application or attached material, during the interview or screening process, or discovered during any employment-related process (post hire) may result in the revoking of a job offer or termination of employment. Typing my name on the signature line qualifies as my acknowledgement and signature.

• I certify that all statements contained herein are true and complete.

• I understand that I must provide proof I am authorized to work in the United States, in accordance with federal law, if I am hired.

• I authorize the employing agency to verify the employment and education information provided in this employment application. • I authorize my driving record to be checked if the position for which I am applying requires driving. • I understand and agree to be subjected to a pre-employment drug screening and criminal history background check, if applicable.

• I understand that I must provide proof I am authorized to work in the United States, in accordance with federal law, if I am hired.

• I authorize the employing agency to verify the employment and education information provided in this employment application.

• I authorize my driving record to be checked if the position for which I am applying requires driving.

• I understand and agree to be subjected to a pre-employment drug screening and criminal history background check, if applicable.

• I am able to perform the essential duties of this position as advertised, with or without reasonable accommodation (required)

Yes

No; Explanation

Explanation

Signature (required)

Date (required)

Veterans’ Preference Form (ORS 408.230)

Veterans who meet the minimum qualifications for a position open for recruitment may be eligible for preference in employment under Oregon law. If you are a Qualified Veteran or Qualified Disabled Veteran and would like to be granted preference in the selection and hiring process for a specific posted job, please fill out this Veterans’ Preference Form and provide proof of eligibility by submitting a copy of form DD-214 or 215 (copy 4). This completed form and required supporting documentation must be submitted with your application for consideration for Veterans’ Preference.

Qualified Veteran Questions: Veterans’ preference may be claimed if you check at least one of the boxes below and provide proof via form DD-214 or 215 (Copy 4) ORS 408.225(f) – I served on active duty with the Armed Forces of the United States:

For a period of more than 90 consecutive days beginning on or before January 31, 1955, and was discharged or released under honorable conditions

Yes

For a period of more than 178 consecutive days beginning after January 31, 1955, and was discharged or released from active duty under honorable conditions

Yes

For a period of 178 days or less and was discharged or released from active duty under honorable conditions because of a service due to a service-related disability

Yes

For a period of 178 days or less and was discharged or released from active duty under honorable conditions and have a disability rating from the United States Department of Veterans Affairs

Yes

For at least one day in a combat zone and was discharged or released from active duty under honorable conditions

Yes

And received a combat or campaign ribbon or an expeditionary medal for service in the Armed Forces of the United States and was discharged or released from active duty under honorable conditions

Yes

And am receiving a nonservice – connected pension from the United States Department of Veterans Affairs

Yes

Qualified Disabled Veteran Questions: Additional preference may be claimed if you check at least one box below and provide proof of eligibility via a copy of DD214 or 15, Copy 4, and a public employment preference letter from the United States Department of Veteran’s Affairs (letter may be requested by calling 800-827-1000)

I am entitled to disability compensation under laws administered by the United States Department of Veterans Affairs; or

I was discharged or released from active duty for a disability incurred or aggravated in the line of duty; or

I was awarded the Purple Heart for wounds received in combat.

I hereby claim Veterans’ Preference, have attached proof of eligibility as directed and certify that the above information is true and correct. I understand that any false statements may be cause for my disqualification, or dismissal, regardless of when discovered.

Signature

Date

Position Applied For

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