Instructions: Enter the information requested on this form. Fields with an Asterisk (*) are required. Click the 'Submit' button on the bottom of this page when completed. How did you hear about this job? * - Select -CraigslistJobdango.comMonster.comThe Oregonian NewspaperOregonJobs.comOregonLive.com Contact Information First Name * Middle Name Last Name * Phone * Email * Address * City * State * Zip * If hired do you have reliable means of transportation to get to work? * - Select -NoYes If you are under 18 years of age, can you provide required proof of your eligibility to work? * - Select -NoYes Are you prevented from lawfully becoming employed in this country because of Visa or Immigration status? * - Select -NoYes Employment Information Type of Employment Desired * - Select -TemporaryPart-TimeFull-Time What position are you applying for? * Please describe your experience, any special skills or training * Please indicate any shifts you would not be available to work * Are you willing to work overtime? * - Select -NoYes Are you currently employed? * - Select -NoYes Salary Requirement * Are you on layoff subject to recall? * - Select -NoYes When would you be able to start work? * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Have you every worked for this organization before? * - Select -No If yes, under what name? Military Service and Education Have you ever serviced in the Armed Forces? * - Select -NoYes Service Dates From Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year To Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Highest level of education attained * - Select -Elementary - 1Elementary - 2Elementary - 3 Elementary - 4 Elementary - 5 Elementary - 6 Elementary - 7 Elementary - 8High School - 9High School - 10High School - 11High School - 12College - 1College - 2College - 3College - 4College - 5College - 6 Name and city of last educational instituion attended * Degree and Major (if applicable) If currently in high school, are you in a recognized co-op program (such as D.E., C.V.A., V.O.E.)? * - Select -No If yes, identify the program and the school Employment HistoryJob 1 Company Start Date Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year End Date Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Your Title Base Salary Your Supervisors Name and Title Your Supervisors Telephone Brief Description of Duties Job 2 Company Start Date Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year End Date Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Your Title Base Salary Your Supervisors Name and Title Your Supervisors Telephone Brief Description of Duties May we contact the employers listed above? * - Select -NoYes Have you ever been convicted of a crime involving dishonesty or breach of trust? * - Select -No If yes, state the nature of the offense and disposition of the case. Include dates and places. Are you able to perform, on a regular basis, the duties of the job, with or without reasonable accommodation? * - Select -NoYes This company is an equal opportunity employer and does not discriminate on the basis of race, color, gender, national origin, age, religion, creed, sexual orientation, disability, marital or veteran status. I authorize this company to make an investigation of all information contained in this application for employment, and I release from all liability all companies and corporations supplying such information. I understand that any false answers or statements or implications made by me in this application or other required documents shall be considered sufficient cause for denial of employment or discharge. Upon termination of my employment, for whatever reason, I release this company from all liability for supplying any information concerning my employment to any potential employer. I authorize this company to request a copy of my credit report from the Credit Bureau, my criminal background record, a copy of my motor vehicle driving record, along with my approval to submit to a physical examination if required, and a drug test either prior to my employment or any time during employment with this company. I further understand that this is an application for employment and that no employment contract is being offered. I understand that if I am employed, such employment is for an indefinite period of time and that the company can change wages, benefits and conditions of employment at any time.