Employment Application
Applicant Information
Name
*
First Name
Middle Name
Last Name
DOB
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Date Available
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Social Security Number
*
Desired Hourly Pay $
*
Position Applied for:
*
Are you a citizen of the United States?
*
YES
NO
If no, are you authorized to work in the U.S.?
*
YES
NO
Have you ever worked for this company?
*
YES
NO
If yes, when?
Have you ever been convicted of a felony?
*
YES
NO
If yes, explain
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Education
High School
*
Address
*
From
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
To
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Did you graduate?
*
YES
NO
Diploma
College
*
Address
*
From
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
To
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Did you graduate?
*
YES
NO
Degree
Other
Address
From
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
To
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Did you graduate?
YES
NO
Degree
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References ( At least one)
Please list three professional references
Full name company
Relationship
Company
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Full name company
Relationship
Company
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Full name company
Relationship
Company
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
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Previous Employment
Company
Phone Supervisor
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Job Title
Starting Salary $
Ending Salary $
Responsibilities
From
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
To
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for Leaving
May we contact your previous supervisor for a reference?
YES
NO
Company
Phone Supervisor
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Job Title
Starting Salary $
Ending Salary $
Responsibilities
From
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
To
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for Leaving
May we contact your previous supervisor for a reference?
YES
NO
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Availability
Full Time
Part Time
On Call
Sunday
Morning
Evening
Nights
Monday
Morning
Evening
Nights
Tuesday
Morning
Evening
Nights
Wednesday
Morning
Evening
Nights
Thursday
Morning
Evening
Nights
Friday
Morning
Evening
Nights
Saturday
Morning
Evening
Nights
Are you willing to work 24 hour live in positions?
YES
NO
Range / Area you are will to work? (Check All that Apply)
0-25 Miles
25-50 Miles
50-75 Miles
75-100 Miles
100+ Miles
Portland Metro Area
Salem Area
Albany / Corvallis Area
Eugene Area
Rural Areas
Oregon Coast
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