Fillable Application for Employment (City of La Pine)

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Application for Employment (City of La Pine)

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U.S.A. forms for City of La Pine

BROWSE CITY OF LA PINE (OR) FORMS

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Application for Employment
The City of La Pine provides equal employment opportunity to all qualified employees and applicants, without regard to race, color,
religion, gender, sexual orientation, national origin, age, disability, genetic information, veteran’s status, or any other status protected
by applicable federal, Oregon, or local law. Our Equal Employment Opportunity policy applies to all aspects of the employment
relationship including, but not limited to, recruitment, hiring, compensation, promotion, demotion, transfer, disciplinary action, layoff,
recall, and termination of employment. To claim veterans’ preference in hiring, complete the Veteran’s Preference Form and submit it
with the required documentation at the time you submit this application.
THIS APPLICATION WILL BE CONSIDERED FOR THIS SPECIFIC JOB. IT WILL NOT BE RETAINED FOR FUTURE
POSITIONS. IF YOU DESIRE TO BE CONSIDERED FOR A POSITION AT A FUTURE TIME, YOU MUST FILE A NEW
APPLICATION. IF HIRED, THIS APPLICATION WILL BE COME PART OF YOUR PERMANENT PERSONNEL FILE.
PLEASE PRINT OR TYPE. YOUR APPLICATION MAY NOT BE CONSIDERED IF INCOMPLETE OR SUBMITTED
PAST AN ESTABLISHED DEADLINE.
Position
Position Applying For
Available Start Date
Personal Information
Name
Address
City
State
Zip
Phone Number
Email Address
Are you able, at the time of employment, to submit verification of your legal right to work in the United States? Yes ☐ No ☐
(Proof of identity will be required upon employment)
Education
List any colleges, military, trade, business or other schools attended.
Do you have a high school diploma or GED Certificate? Yes
☐
No
☐
School Name
Location
Diploma/Degree
Major/Minor
Did you
Graduate?
Certificates & Licenses
List any professional license, registration, or certificate required or preferred for
the position.
Type
Issuing Agency
Date Issued
Date Expires
References
Name
Title
Company
Phone
Employment History
This information in this section will be used to determine if you meet the minimum qualifications as outlined in the job announcement.
List ONLY the job(s) (paid, military or volunteer) where you obtained the experience that qualifies you for the job. Clearly describe all
of your duties, starting with your most recent job. Resumes will be accepted only if required on the job announcement and will not be
accepted in place of a completed application. If you need additional space, attach a separate sheet.
Employer (1)
Job Title
Dates Employed
Address
City
State
Zip
Supervisor Name
Phone Number
May we contact?
Yes
☐
No
☐
Reason for leaving
Duties
Employer (2)
Job Title
Dates Employed
Address
City
State
Zip
Supervisor Name
Phone Number
May we contact?
Yes
☐
No
☐
Reason for leaving
Duties
Employer (3)
Job Title
Dates Employed
Address
City
State
Zip
Supervisor Name
Phone Number
May we contact?
Yes
☐
No
☐
Reason for leaving
Duties
Employer (4)
Job Title
Dates Employed
Address
City
State
Zip
Supervisor Name
Phone Number
May we contact?
Yes
☐
No
☐
Reason for leaving
Duties
Certification & Signature
I hereby certify that all statements made in this application are true, and I agree and understand that any statement that is false,
fraudulent, or misleading in this application or attached material, during the interview or screening process, or discovered in the
course of any employment-related process (post hire) may result in the revoking of a job offer or termination of employment.
• I certify that all statements contained herein are true and complete.
• I understand that I must provide proof I am authorized to work in the United States, in accordance with federal law, if I
am hired.
• I authorize the employing agency to verify the employment and education information provided in this employment
application.
• I authorize my driving record to be checked if the position for which I am applying requires driving.
• I understand and agree to be subjected to a pre-employment drug screening and criminal history background check, if
applicable.
Signature: _____________________________________________________________ Date: _____________________
Veterans’ Preference Form (ORS 408.230)
Veterans who meet the minimum qualifications for a position open for recruitment may be eligible for preference in
employment under Oregon law. If you are a Qualified Veteran or Qualified Disabled Veteran and would like to be granted
preference in the selection and hiring process for a specific posted job, please fill out this Veterans’ Preference Form and
provide proof of eligibility by submitting a copy of form DD-214 or 215 (copy 4). This completed form and required
supporting documentation must be submitted with your application in order for consideration for Veterans’ Preference.
Qualified Veteran Questions: Veterans’ preference may be claimed if you check at least one of the boxes below and
provide proof via form DD-214 or 215 (Copy 4)
ORS 408.225(f) – I served on active duty with the Armed Forces of the United States:
___ For a period of more than 90 consecutive days beginning on or before January 31, 1955, and was discharged or released
under honorable conditions
___ For a period of more than 178 consecutive days beginning after January 31, 1955, and was discharged or released from
active duty under honorable conditions
___ For a period of 178 days or less and was discharged or released from active duty under honorable conditions because
of a service due to a service related disability
___ For a period of 178 days or less and was discharged or released from active duty under honorable conditions and have
a disability rating from the United States Department of Veterans Affairs
___ For at least one day in a combat zone and was discharged or released from active duty under honorable conditions
___ And received a combat or campaign ribbon or an expeditionary medal for service in the Armed Forces of the United
States and was discharged or released from active duty under honorable conditions
___ And am receiving a nonservice – connected pension from the United States Department of Veterans Affairs
Qualified Disabled Veteran Questions: Additional preference may be claimed if you check at least one box below and
provide proof of eligibility via a copy of DD214 or 15, Copy 4, and a public employment preference letter from the United
States Department of Veteran’s Affairs (letter may be requested by calling 800-827-1000)
___ 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 Veterans’ Preference, have attached proof of eligibility as directed and certify that the above information is
true and correct. I understand that any false statements may be cause for my disqualification, or dismissal, regardless of
when discovered.
Signature: _________________________________________________ Date: __________________
Position Applied For: __________________________________________________
This form and supporting documentation must be received by the Human Resources Department no later than the closing
time and date of the job posting. If you have any specific questions please contact the City Recorder.
(541) 536-1432 or email rneace@lapineoregon.gov
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Application for Employment (City of La Pine)

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Completed 23 January 2021

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