Fillable CITY OF LA PINE EMPLOYMENT APPLICATION City of (City of La Pine)

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CITY OF LA PINE EMPLOYMENT APPLICATION City of (City of La Pine)

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{14323313-00797738;1}
CITY OF LA PINE
EMPLOYMENT APPLICATION
City of La Pine (“City”), an Oregon municipal corporation, is an Equal Opportunity Employer and considers applicants for all
positions without regard to race, color, religion, national origin, age, sex, marital or veteran status, disability, sexual orientation,
and/or any other legally protected status. City is a drug-free workplace. Individuals who require an accommodation relating to
the application process should request the accommodation in advance so that necessary arrangements can be made. Please
contact City if there is any part of this application that you do not understand before signing.
Print or type the required information. Please answer every applicable question. Write “N/A” if a particular question or matter
is not applicable to you. If additional space is needed, please attach a separate sheet. Because this application may be used for
investigative purposes, DO NOT misstate or omit any material facts or information. Statements made herein are subject to
verification to determine your qualification for employment. If you are employed by City, this application will become part of
your personnel file.
Candidates eligible for Veterans Preference must include a required Veterans Preference Form and appropriate certification
to receive Veteran’s Preference Points. Refer to the Veterans Preference Form as applicable.
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------
GENERAL INFORMATION
_____________________________________________________ __________________________
Position Date of Application
________________________________________________________________________________________________________
Last Name First Name Middle
________________________________________________________________________________________________________
Address/PO Box City State Zip
Telephone No: ____________________________ ___________________________
Home Cellular
Email Address: ___________________________ Are you at least 18 years of age: Yes No
Are you (or will you be) legally eligible for employment in the US as of the date of employment? Yes ____ No ____
Date you can report to work: _________________ Hours available for work: __________________
Are you available to work full-time, part-time, or on a temporary basis: ___________
Are you able to travel if required: Yes No
Do you possess a valid Oregon driver’s license: Yes No ODL No.: __________________
(A valid Oregon driver’s license is required when stated on the job announcement or job description. If not required, write
“N/A”).
Have you ever had your license suspended or revoked: Yes ____ No _____ If yes, please explain:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Are you a veteran? Yes* No
*Complete and attach form DD 214 or 215 to this application. If applicable, disabled veterans may also submit a copy of a
disability preference letter.
EDUCATION AND TRAINING
Did you graduate from high school or receive an equivalent diploma: Yes No
Name of college or university you attended, if any:
________________________________________________________________________________________________________
From (mo/yr): ___________ To (mo/yr): ___________ Year of graduation: _______________
Major: __________________________ Minor: _____________________________
Certificates, degrees, etc. earned: ____________________________________________________________________________
Name of college or university you attended, if any:
________________________________________________________________________________________________________
From (mo/yr): ___________ To (mo/yr): ___________ Year of graduation: _______________
Major: __________________________ Minor: _____________________________
Certificates, degrees, etc. earned: ____________________________________________________________________________
Have you received any specialized schooling or training: Yes No
Name of school or training program: __________________________________________________________________________
From (mo/yr): ___________ To (mo/yr): ___________ Year of graduation: _______________
Major: ________________________ Minor: _________________________
Certificates, degrees, etc. earned: ____________________________________________________________________________
Please identify below any special training, licenses, and/or certificates, any experience with machines, office equipment, and/or
languages, and any other special skills pertinent to the position for which you are applying:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
A job description for the position(s) for which you are applying has been provided. Are you able to perform the essential job
functions required of the position with or without reasonable accommodation(s)? Yes ___ No
WORK EXPERIENCE
List below all work experience for the past 10 years, paid or unpaid, beginning with your most recent job, including military,
volunteer, and other jobs. Attach additional pages if necessary.
Employer: ______________________________________ Job Title: _________________________
Supervisor’s Name and Title: _____________________________________________________________
Part Time: From (mo/yr): _____ To (mo/yr): _____ Full Time: ___
Specific Duties: ___________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Reason for Leaving: _______________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
May we contact this employer: Yes No
{14323313-00797738;1}
{14323313-00797738;1}
Employer: ______________________________________ Job Title: _________________________
Supervisor’s Name and Title: _____________________________________________________________
Part Time: From (mo/yr): _____ To (mo/yr): _____ Full Time:
Specific Duties: ___________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Reason for Leaving: ________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
May we contact this employer: Yes No
Employer: ______________________________________ Job Title: _________________________
Supervisor’s Name and Title: _____________________________________________________________
From (mo/yr): _____ To (mo/yr): _____ Full Time: Part Time:
Specific Duties: ___________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Reason for Leaving: ________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
May we contact this employer: Yes No
Have you ever been terminated from a job or asked to resign: Yes ____ No ____ If yes, please explain:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
REFERENCES
Name: Relationship:
Address: Telephone Number:
Name: Relationship:
Address: Telephone Number:
SUPPLEMENTALS TO THIS APPLICATION MAY BE NECESSARY (AND BECOME PART OF THIS APPLICATION). THESE
SUPPLEMENTALS CONCERN CRIMINAL BACKGROUND CHECKS AND CREDIT CHECKS. PLEASE INQUIRE WHETHER ANY
SUPPLEMENTALS ARE NECESSARY IN CONNECTION WITH YOUR APPLICATION.
APPLICANT CERTIFICATION AND ACKNOWLEDGMENT
Please initial next to each paragraph and sign where indicated below.
_____ I certify that all statements made in connection with this application (whether contained herein (and/or in any
supplements) or made by me or others at my request during the course of the employment process) are true and complete in
all respects. I acknowledge and agree that any incorrect, incomplete, false, fraudulent, or misleading statements made by me,
either verbally or in writing, and/or any omission, concealment, or failure to answer any question fully, completely, and
accurately, whether made by me or others at my request, will result in rejection of this application, denial of employment, or
termination from employment if discovered after employment. If I am employed by City, I agree to comply with its lawful
orders, rules, policies, and regulations.
{14323313-00797738;1}
_____ I authorize the investigation of all matters which City deems relevant to my qualifications for employment, including,
without limitation, work records, reference checks, education, and an investigation into my driving record. I authorize and
request that all my present and former employers, references, educational institutions, and any others to furnish and release
information about me, my employment record, and/or education, including a statement of reasons for the termination of my
employment and information regarding my work performance, disciplinary reports or actions, abilities, degrees obtained,
transcripts, licenses and certifications, and other qualities and information City deems pertinent to my qualifications for
employment. By signing below, I release City (and all providers of information) from all claims and/or liabilities arising out of or
in any way connected with City’s background investigation. If employed, I release City from any claims and/or liabilities for
future references it may provide regarding my work history and performance with City.
_____ I understand that if offered employment, I will be required to submit proof of my identity and legal right to work in the
United States as a condition of employment.
_____ I understand that, if employed, my employment relationship with City will be at-will. Therefore, subject to applicable
law, my employment may be terminated (and I may voluntarily resign) at any time, for any reason or no reason, with or without
cause or prior notice. Nothing contained in this application, or provided in connection herewith, will be construed as an offer
or promise of employment, nor does this application create an employment contract or guarantee that employment or any
benefit will be provided or continued for any period of time.
By signing below, I hereby affirm the foregoing and all other contents of this application. My signature below certifies that I
have read and understand this application and agree to the terms and conditions contained in this application.
Applicant’s Signature Date
FOR MANAGEMENT USE ONLY
Date Application Received: ___________________
Supplementals to Application Required: Yes ___ No ___
Arrange Interview:
Yes ___ No ___
_______________________________
Interviewer Date
Employ:
Yes ___ No ___
Date of Employment: ___________ Job Title: _____________________
Hourly/ Salary Rate: _______________ Department: __________________________________________
By: __________________________________________ _______________________________
Name and Title Date
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CITY OF LA PINE EMPLOYMENT APPLICATION City of (City of La Pine)

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Completed 18 February 2021

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