Mid Oregon Personnel Application 09-2025

Mid Oregon Personnel Application 09-2025

Application for Employment

PLEASE FILL OUT APPLICATION COMPLETELY. INCOMPLETE APPLICATIONS WILL NOT BE ACCEPTED. FILL OUT ALL FIELDS AND DO NOT WRITE "SEE RESUME."
WE ARE AN EQUAL OPPORTUNITY EMPLOYER
- Date
  
  MonthDayYear
  Date
- Last Name
- First Name
- Middle Name
- Email Address
  example@example.com
- Address
  Street Address
- City
- Zip Code
- Phone Number
  Format: (000) 000-0000.
- Which office are you applying with?
- Date Entered
  
  MonthDayYear
  Date
- Date Separated
  
  MonthDayYear
  Date
- Honorable?
- Rank
- Branch
- Occupation
- HIGH SCHOOL
- Highest Level of Education
- Name and Location of Highschool
- Graduated?
- School #1: Name & Location
- School #1: Full-time/Part-time
- School #1: List your major and minor
- School #1: Semester Hours Completed
- School #1: Quarter Hours Completed
- School #1: Did you graduate?
- School #1: Certificate/Degree Earned
- School #2: Name & Location
- School #2: Full-time/Part-time
- School #2: List your major and minor
- School #2: Semester
- School #2: Quarter
- School #2: Did you graduate?
- School #2: Certificate/Degree Earned
- School #3: Name & Location
- School #3: Full-time/Part-time
- School #3: List your major and minor
- School #3: Semester
- School #3: Quarter
- School #3: Did you graduate?
- School #3: Certificate/Degree Earned
- Please provide the last four digits of your Social Security Number
- Will you be able to provide proof of Citizenship or an alien registration number and visa permitting work in this country?
- I hereby authorize you to consult and obtain information from any employer I am working or have worked for:
- All three references, name and phone number, are required. Email is preferred but not required. References will be verified.
- Reference #1: Name
- Reference #1: Phone
  Format: (000) 000-0000.
- Reference #1: Email
  example@example.com
- Reference #2: Name
- Reference #2: Phone
  Format: (000) 000-0000.
- Reference #2: Email
  example@example.com
- Reference #3: Name
- Reference #3: Phone
  Format: (000) 000-0000.
- Reference #3: Email
  example@example.com
- 1. Positions Desired (preference order):
- 1.
- 2.
- 3.
- 2. Are you seeking Regular Employment?
- Part-time Employment?
- 3. If seeking temporary employment only when would you expect to terminate?
  
  MonthDayYear
  Date
- 4. Date you can start
  
  MonthDayYear
  Date
- 5. SalaryWage desired
- 6. Are you willing to accept odd (nights, graveyard or weekend) or rotating shifts?
- 7. Have you ever applied to this company before?
- If yes, when and where?
- 8. Which of the following are you able to lift and/or carry for prolonged periods?
- 20 lbs?
- 30 lbs?
- 40 lbs?
- 50 lbs?
- 50+ lbs?
- 9. What you have done in the recent past to demonstrate that you can perform the activities in Question 8 above
- 10. How many days did you miss from work this past year
- EMPLOYMENT HISTORY
  
  PLEASE LIST YOUR EMPLOYERS STARTING WITH YOUR MOST RECENT POSITION
- Start Date
  
  MonthDayYear
  Date
- End Date
  
  MonthDayYear
  Date
- Name and Location of Company
- Company Phone Number
  Format: (000) 000-0000.
- Reason for Leaving
- Immediate Supervisor
- Duties Performed
- Start Date
  
  MonthDayYear
  Date
- End Date
  
  MonthDayYear
  Date
- Name and Location of Company
- Company Phone Number
  Format: (000) 000-0000.
- Reason for Leaving
- Immediate Supervisor
- Duties Performed
- Start Date
  
  MonthDayYear
  Date
- End Date
  
  MonthDayYear
  Date
- Name and Location of Company
- Company Phone Number
  Format: (000) 000-0000.
- Reason for Leaving
- Immediate Supervisor
- Duties Performed
- Start Date
  
  MonthDayYear
  Date
- End Date
  
  MonthDayYear
  Date
- Name and Location of Company
- Company Phone Number
  Format: (000) 000-0000.
- Reason for Leaving
- Immediate Supervisor
- Duties Performed
- List Here:
- File Upload - Please upload any additional documents here: Resume, cover letter, etc.
  
  Cancelof
- I authorize the investigation of all matters which PSI deems relevant to my qualifications for employment, including all statements made in this application and in any attachments or supporting documents. I authorize PSI to request, receive and share with any agent or client employer such information and I release from all liability any persons, such as but not limited to, supervisors or employers supplying it. I also release PSI and any of its agents or client employers from all liability which might result from making the investigations.
  
  If employed, I understand that misrepresentation or omission of facts called for is cause for dismissal. If offered employment, I am also willing to take a physical examination and authorize the doctor or doctors involved to disclose to the prospective employer here and any of its agents or client employers the results of that examination. I agree to comply with the employer's substance abuse program, including drug testing as may be required. If employed, I agree to conform to the rules of this company, and hereby acknowledge that my employment with the company can be terminated at any time, with or without cause, at the option of either myself or the company. I further understand and acknowledge that nothing contained in any employee handbook or policy statement nullifies or modifies the foregoing employment at will policy.
  
  PLEASE REVIEW APPLICATION FOR COMPLETION. INCOMPLETE APPLICATIONS WILL NOT BE ACCEPTED.
- By this application and my signature I authorize you to check the validity of my social security number and other pertinent identification INITIAL HERE
- DATE
  
  MonthDayYear
  Date
- APPLICANTS SIGNATURE
- Should be Empty: