Careers 1Personal2Education3Background4Experience5Requirements Personal InformationYour Name(Required) First Middle Last Maiden Present Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code How long at this address?(Required) Email Address(Required) Phone (Landline)Phone (Mobile)Date of Birth(Required) MM slash DD slash YYYY Social Security # (last 4 digits only)(Required)ScheduleWhen can you start work?(Required) MM slash DD slash YYYY How many hours can you work weekly?(Required)Employment Desired(Required) FULL Time PART Time I can work the following shifts:(Required)(check all that apply) Day Night Swing Graveyard Select AllAre you legally eligible for employment in the U.S.?(Required) Yes, I am legally eligible to work in the United States. Emergency ContactIn case of accident or illness, please contact:(Required) Daytime Phone(Required)Relationship(Required) EducationName of High School Location (city/state) Years CompletedMajor & Degree Name of College Location (city/state) Years CompletedMajor & Degree Name of Business or Trade School Location (city/state) Years CompletedMajor & Degree Name of Professional School Location (city/state) Years CompletedMajor & Degree BackgroundHave you ever been convicted of a crime?(Required)(including military convictions and traffic violations / infractions) No Yes Message here about the re-entry program.Please explain:(Required)If you answered yes, explain the number of convictions, nature of offenses leading to convictions, how recently such offenses were committed, sentences imposed and types of rehabilition (if any).MilitaryHave you ever been in the Armed Forces?(Required) Yes No Are you now a member of the National Guard?(Required) Yes No Since Date(Required) MM slash DD slash YYYY Discharge Date MM slash DD slash YYYY Was it an Honorable Discharge? Yes No Work ExperiencePlease list your work experience for the past three years beginning with your most recent job held. If you were self-employed, give firm name.Most Recent EmployerName of Employer Supervisor Name Phone NumberEmployer Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Start Date MM slash DD slash YYYY Termination Date MM slash DD slash YYYY Rate of Pay Job Title Reason for Leaving List the type of work performed, tools/equipment used, training received:Previous EmployerName of Employer Supervisor Name Phone NumberEmployer Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Start Date MM slash DD slash YYYY Termination Date MM slash DD slash YYYY Rate of Pay Job Title Reason for Leaving List the type of work performed, tools/equipment used, training received:Previous EmployerName of Employer Supervisor Name Phone NumberEmployer Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Start Date MM slash DD slash YYYY Termination Date MM slash DD slash YYYY Rate of Pay Job Title Reason for Leaving List the type of work performed, tools/equipment used, training received: Job RequirementsDo you have a current, valid Oregon Driver's license? Yes No License Number(Required) Expiration(Required) MM slash DD slash YYYY Have you had any traffic accidents in the past 3 years? Yes No How many?(Required)Are you physically able to perform the essential functions of the position you are applying for? Yes No I understand that I will be required to show negative results on a 7-panel drug test prior to the start of my employment. Yes, I understand. ReferencesPlease list two references other than relatives or previous employers:Name(Required) Relationship(Required) Phone(Required)Name(Required) Relationship(Required) Phone(Required)Information to the ApplicantAs part of our procedure for processing your employment application, your personal and employment references may be checked. If you have misrepresented or omitted any facts on this application, and you are subsequently hired, you may be discharged from your job. You may make a written request for information derived from the checking of your reference. If employment commences, you will be required to provide two acceptable forms of identification as proof of authorization to work in the United States, a request for Oregon criminal offender information will be required and a clean drug test will also be required. I understand and agree to the information shown above.Signature of Applicant(Required)Date(Required) MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged. Δ
