Employment Application POSITION Position Applying For (required) Available Start Date (required) Today's Date (required) PERSONAL INFORMATION Your 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 No EDUCATION List any colleges, military, trade, business, or other schools attended. Do you have a high school diploma or GED Certificate? (required) Yes No 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 No Reason for leaving Employer (2) Job Title Dates Employed (from-to) Address City, State, Zip Supervisor Name Phone Number May we contact? Yes No 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) Email Name (2) (required) Title Company Relationship to you (required) Phone (required) Email Name (3) (required) Title Company Relationship to you (required) Phone (required) Email 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. DD-214 or DD-215 Submission: Upload a copy of your DD214 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 conditionsYes For a period of more than 178 consecutive days beginning after January 31, 1955, and was discharged or released from active duty under honorable conditionsYes 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 disabilityYes 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 AffairsYes For at least one day in a combat zone and was discharged or released from active duty under honorable conditionsYes 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 conditionsYes And am receiving a nonservice – connected pension from the United States Department of Veterans AffairsYes 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; orYes I was discharged or released from active duty for a disability incurred or aggravated in the line of duty; orYes I was awarded the Purple Heart for wounds received in combat.Yes 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 There was a problem saving your submission. Please try again later. Please wait while your submission is being saved... Submitting...Submit Thank you, your submission has been received.
