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

Applicant Information
Date*

MonthDayYear
Date
Last Name*
First Name*
Middle Name
Email Address*
example@example.com
Address*
Street Address
City*
Zip Code*
Phone Number*
Which office are you applying with?*

Military Service
Date Entered

MonthDayYear
Date
Date Separated

MonthDayYear
Date
Honorable?

YesNo
Rank
Branch
Occupation

High School Education
HIGH SCHOOL
Highest Level of Education*
Name and Location of Highschool*
Graduated?*

YesNoGED

Schools attended after High School or special training
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?

YesNo
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?

YesNo
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?

YesNo
School #3: Certificate/Degree Earned

Additional Information
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?*

YesNo
I hereby authorize you to consult and obtain information from any employer I am working or have worked for:*

YesNo

Professional References
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*
Reference #1: Email
example@example.com
Reference #2: Name*
Reference #2: Phone*
Reference #2: Email
example@example.com
Reference #3: Name*
Reference #3: Phone*
Reference #3: Email
example@example.com

Most Recent Position
Start Date*

MonthDayYear
Date
End Date

MonthDayYear
Date
Name and Location of Company*
Company Phone Number*
Reason for Leaving*
Immediate Supervisor*
Duties Performed*

Previous Position
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Name and Location of Company
Company Phone Number
Reason for Leaving
Immediate Supervisor
Duties Performed
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Name and Location of Company
Company Phone Number
Reason for Leaving
Immediate Supervisor
Duties Performed

Previous Position
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Name and Location of Company
Company Phone Number
Reason for Leaving
Immediate Supervisor
Duties Performed

Special Skills
List Here:*

Optional resume/cover letter upload
File Upload - Please upload any additional documents here: Resume, cover letter, etc.

Cancelof

Authorization
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*

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DATE*

MonthDayYear
Date
APPLICANTS SIGNATURE*

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