Fillable APPLICATION FOR EMPLOYMENT (City of La Grande, Oregon)

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APPLICATION FOR EMPLOYMENT (City of La Grande, Oregon)

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[1]
THE HUB OF NORTHEASTERN OREGON
APPLICATION FOR EMPLOYMENT
The City of La Grande makes its employment decisions without regard to race, color, sex, national
origin, religion, marital status, age, prior industrial injury, or mental or physical disabilities unrelated
to job performance.
It is the policy of the City to accept applications only when it advertises for an open position. This
application may be considered for other positions within the classification of the position for which you
are applying. However, if you desire to apply to another advertised position, you must complete a new
application.
POSITION APPLIED FOR:____________________________ DATE:____________________________
NAME:_________________________________________________________________________________
(Last) (First) (Middle)
ADDRESS:______________________________________________________________________________
(Street/P.O. Box) (City) (State) (Zip Code)
PHONE NUMBERS: Daytime (_____) ______-____________ Evening (_____) _______-____________
EMAIL: ____________________________________________
Are you over the age of eighteen (18)? Yes___ No___ If No, applicant is subject to verification of
minimum legal age.
Are you legally eligible for employment in the USA? Yes____ No____ If hired, you are required to
submit proof of eligibility to work in the USA.
Have you ever worked for the City of La Grande? Yes ___ No ___ If so, please indicate the position
held and dates worked.
_________________________________________________________________________
If the job requires, do you have a valid driver’s license? Yes____ No____
AN EQUAL OPPORTUNITY EMPLOYER
CITY OF
LA GRANDE
[2]
PREVIOUS WORK EXPERIENCE: (Please list employment for the past ten (10) years, beginning
with your present or most recent position. Use a separate sheet if more than three (3) employers.)
1) EMPLOYER’S NAME:_____________________________ PHONE NUMBER:______________
ADDRESS:________________________________________________________________________
DATES WORKED:___________________________ POSITION HELD:____________________
IMMEDIATE SUPERVISOR:_______________________
JOB RESPONSIBILITIES, EQUIPMENT OPERATED:_________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
REASON FOR LEAVING:__________________________________________________________
2) EMPLOYER’S NAME:_____________________________ PHONE NUMBER:______________
ADDRESS:________________________________________________________________________
DATES WORKED:___________________________ POSITION HELD:____________________
IMMEDIATE SUPERVISOR:_______________________
JOB RESPONSIBILITIES, EQUIPMENT OPERATED:_________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
REASON FOR LEAVING:__________________________________________________________
3) EMPLOYER’S NAME:_____________________________ PHONE NUMBER:______________
ADDRESS:________________________________________________________________________
DATES WORKED:___________________________ POSITION HELD:____________________
IMMEDIATE SUPERVISOR:_______________________
JOB RESPONSIBILITIES, EQUIPMENT OPERATED:_________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
REASON FOR LEAVING:__________________________________________________________
May we make inquiries of present employer(s)? _______________________________________________________
[3]
EDUCATION AND OTHER QUALIFICATIONS:
Please describe any training, skills, certifications, licenses or other qualifications you have which you
believe are relevant to the position you are applying for.
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
State any additional information you feel may be helpful to us in considering your application.
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
HOURS: (The City requires all employees to maintain regular attendance. Some employees work
day, swing and evening shifts. The attached position description may indicate the normal hours of the
position for which you are applying. Please indicate which shifts you would be unable or unwilling to
work on a regular schedule.)
________________________________________________________________________________________________
________________________________________________________________________________________________
TYPE
NAME OF SCHOOL
LOCATION
AREA OF
CONCENTRATION
CIRCLE LAST YEAR
COMPLETED
DIPLOMA, DEGREE OR
CERTIFICATE
1
2
3
4
HIGH SCHOOL
1
2
3
4
COLLEGE
1
2
3
4
OTHER
EDUCATION
1
2
3
4
SPECIAL SCHOOLING OR TRAINING/APPRENTICESHIP:
[4]
REFERENCES: (List three (3) persons, other than relatives, who have known you longer than one
(1) year.)
1) NAME:__________________________________________ OCCUPATION:________________________
ADDRESS:______________________________________ PHONE NUMBER:____________________
2) NAME:__________________________________________ OCCUPATION:________________________
ADDRESS:______________________________________ PHONE NUMBER:____________________
3) NAME:__________________________________________ OCCUPATION:________________________
ADDRESS:______________________________________ PHONE NUMBER:____________________
It is the policy of the City to comply with the provisions of the Immigration Reform and Control Act of
1986 and to hire only authorized workers. If you are hired, you will be asked to provide verification of
your work eligibility. The type of verification required may change from time to time as Federal
regulations are promulgated or amended. Your employment will not be continued if you are unable or
unwilling to provide the verification requested by the City.
In submitting this application for employment, I authorize investigation of all statements contained in it,
and it is understood and agreed that any misrepresentation by me in this application may result in
cancellation of the application and/or separation from the City’s service if I have been employed. If
requested by the City, I agree that I will undergo a physical examination, at the City’s expense.
I understand that this application does not, by itself, create a contract of employment. I understand and
agree that, if hired, MY EMPLOYMENT IS FOR NO DEFINITE PERIOD OF TIME, and may,
regardless of the date of payment of my wages or salary, BE TERMINATED AT ANY TIME, subject to
City’s policies and rights provided by written contract. I understand that NO PERSON IS
AUTHORIZED TO CHANGE ANY OF THE TERMS MENTIONED IN THIS EMPLOYMENT
APPLICATION FORM.
I certify I have read all of this application, and the information I have provided on all four (4) pages, as
well as any pages I have attached to the application, is true and correct.
INCOMPLETE APPLICATIONS WILL NOT BE CONSIDERED.
__________________________________________________ __________________________________
Signature Date
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The
CITY OF LA GRANDE
Is an EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER
VOLUNTARY SURVEY
Periodically we may be required to file reports on the sex, ethnicity, disability, veteran and
other protected status of employees.
As a public employer who subscribes to the merit principles, we are extremely desirous that
information relative to employment opportunities with the City of La Grande reaches all
segments of our community. By completing this form, you will aid us in determining how we
are succeeding in being an “Equal Opportunity and Affirmative Action Employer.”
Thank you for you cooperation.
1) POSITION APPLYING FOR: __________________________________
2) DATE: ________________________________
3) AGE: __________________________________
4) HOW DID YOU LEARN ABOUT THIS JOB OPENING?
City Job Announcement
Employment Agency
Professional/Association/Publication
City Employee
The Observer
School
Other
5) RACE/ETHNIC IDENTIFICATION:
Asian/Pacific Island
Caucasian
Native American/Alaskan Eskimo
Black
Hispanic
6) HANDICAP/DISABILTIY: Yes No
7) VETERAN: Yes No
City of La Grande
Veteran’s Preference Form
Under Oregon law, veterans who meet minimum qualifications for a position may be eligible for employment
preference. If you think you may qualify, please read the following checklist carefully. Check the box for each item
that is appropriate.
This completed form and required documentation must be submitted to the City of La Grande Human Resources
Department at the time you submit your employment application.
A. QUALIFIED VETERAN QUESTIONS: You may claim veteran’s preference if you check at least one box
in each of the four sections below and provide proof of eligibility by submitting a copy of your DD-214 and
215.
ORS 408.225(d)
I served on active duty with the Armed Forces of the United States for a period of more than 178
consecutive days and was discharged or released under honorable conditions; or
I served on active duty with the Armed Forces of the United states for 178 days or less and was discharged
or released from active duty under honorable conditions because of service-connected disability; or
I served on active duty with the Armed Forces of the United States for at least one day in a combat zone and
was discharged or released from active duty under honorable conditions; or
I received a combat or campaign ribbon for service in the Armed Forces of the United States.
“Active duty” does not include attendance at a school under military orders, except schooling incident to an active
enlistment or a regular tour of duty, or normal military training as a reserve officer or member of an organized reserve or
a National Guard unit.
B. QUALIFIED DISABLED VETERAN QUESTIONS: You may claim additional employment preference if
you can check at least one box in each of the three sections below and provide proof of eligibility by submitting
both of the documents listed below:
1. A copy of your DD 214 and 215, Certificate of Release or Discharge, Copy 4, and
2. A public employment preference letter from the United States Department of Veterans’ Affairs. To
order the letter, call 1-800-827-1000 and request a public employment preference letter.
ORS 408.225(b)
I am entitled to disability compensation under laws administered by the United States Department of
Veterans Affairs; or
I was discharged or released from active duty for a disability incurred or aggravated in the line of duty;
or
I was awarded the Purple Heart for wounds received in combat.
I hereby claim veteran’s preference points and certify that the above information is true and correct. I understand any
false statements may be cause for my disqualification or dismissal, regardless of when discovered.
__________________________________________ _____________________________________
Print Name Social Security Number
__________________________________________ _____________________________________
Signature of Applicant Date
Position Applied For:___________________________________________
ORS 408.255.230: Preference will not be awarded without the appropriated documentation. You must submit your DD-214 and
215 in all cases. If you are claiming disabled veteran points, you must also submit the public employment preference letter from
the Department of Veterans Affairs. You will not receive preference without these accompanying documents.
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APPLICATION FOR EMPLOYMENT (City of La Grande, Oregon)

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Completed 2 June 2021

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