Employment Application 2

Employment Application

We are an Equal Opportunity Employer. We comply with all applicable Federal, State, and local laws concerning discrimination in employment. No question on this application is intended to elicit information in violation of any such law nor will any information obtained in response to any question be used in violation of any such law.

Education

Name/location of High School *

Number of years completed *

Course of study *

Did you graduate?

Yes No

Diploma or degree *

Name/location of College *

Number of years completed *

Course of study *

Did you graduate

Yes No

Diploma or degree *

Describe any specialized training, apprenticeship, skills and extra-curricular activities *

References

Reference 1

Name and Address *

Relationship *

Telephone Number *

Reference 2

Name and Address *

Relationship *

Telephone Number *

Reference 3

Name and Address

Relationship

Telephone Number

Reference 4

Name and Address

Relationship

Telephone Number

Reference 5

Name and Address

Relationship

Telephone Number

Employment Experience

^{List most recent employment first}

Job #1

Start Date *

End Date *

Company Name *

Address *

Telephone Number *

Position Held *

Work Performed *

Supervisor's Name *

Supervisor's Title *

Reason for leaving *

Job #2

Start Date *

End Date *

Company Name *

Address *

Telephone Number *

Position Held *

Work Performed *

Supervisor's Name *

Supervisor's Title *

Reason for leaving *

Job #3

Start Date

End Date

Company Name

Address

Telephone Number

Position Held

Work Performed

Supervisor's Name

Supervisor's Title

Reason for leaving

Job #4

Start Date

End Date

Company Name

Address

Telephone Number

Position Held

Work Performed

Supervisor's Name

Supervisor's Title

Reason for leaving

Criminal Background Check

In accordance with ORS 181.537, persons selected for employment will be required to pass a criminal records check, which involves specific paperwork and fingerprinting. Approval for employment under this rule is to be determined by the Mental Health and Developmental Disability Services Division (MHDDSD).

I understand the above statement and will participate in the process if a position is appointed to me.

I agree I disagree

Drug Testing

Rockwest participates in the Drug-Free Workplace Act of 1988 which takes steps to assure that unlawful manufacture, distribution, dispensation, possession, or use of controlled substances will not occur. In order to maintain this standard new hires and current employees will be asked to participate in the Drug Testing Program.

I understand the above statement and will participate in the process if a position is appointed to me.

I agree I disagree

Reference Check and Application Information Investigation

Rockwest will need to receive information from present or former employers and personal references in order to determine the right person for the job. We will also need to verify information on this application.

I authorize Rockwest to investigate all statements contained in this application and my experience/skills for employment as may be necessary in arriving at an employment decision.

I agree I disagree

Application Statement

I certify that answers given in this application are true and complete to the best of my knowledge. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand that signing of this application does not constitute a written employment agreement.

This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time should inquire as to whether or not applications are being accepted at that time. I understand, also, I am required to abide by all rules and regulations of the employer.

I agree I disagree