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In compliance with Federal and State Equal Employment (City of Veneta)

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  • 31 check-boxes
  • 75 other fields

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U.S.A. forms for City of Veneta

BROWSE CITY OF VENETA (OR) FORMS

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Page 1 of 5
PO Box 458 * Veneta, OR 97487 * 541-935-2191 * Fax 541-935-1838 * www.venetaoregon.gov
In compliance with Federal and State Equal Employment Opportunity Laws, qualified applicants are
considered for all positions without regard to race, color, religion, sex, national origin, age, marital status,
legally protected disability, or any other protected class.
PLEASE TYPE OR PRINT CLEARLY
Name:
Last First Middle
Address:
Street City State
Zip Code
Mailing Address if Different:
Phone Number:
Email:
Position Applied For:
Referral Source:
Are you legally able to work in the United States? Yes No
On what date would you be available for work?
Are you available to work: (mark all that apply) Full time Part Time Shift Work
Temporary Nights Weekends
If you are under 18 years of age, can you provide proof of your date of birth? Yes No Over 18
List professional and leisure organizations and/or clubs you are affiliated with:
(Include civic, volunteer work, and extra-curricular activities. You may exclude membership which would
reveal gender, race, national origin, age, ancestry, disability, or other protected status.)
Application for
Employment
Page 2 of 5
Employment Experience
Provide the following information, starting with your present or last employer. You may exclude any employment that
could indicate race, color, religion, gender, national origin, disabilities, or other protected status.
(1) Employer Name:
Address:
Supervisor Name: Telephone No.:
Position(s) Held:
Date Hired: Date Left:
Primary Duties:
Were you terminated for misconduct or poor work performance? Yes No
May we contact this Employer? Yes No
(2) Employer Name:
Address:
Supervisor Name: Telephone No.:
Position(s) Held:
Date Hired: Date Left:
Primary Duties:
Were you terminated for misconduct or poor work performance? Yes No
May we contact this Employer? Yes No
(3) Employer Name:
Address:
Supervisor Name: Telephone No.:
Position(s) Held:
Date Hired: Date Left:
Primary Duties:
Were you terminated for misconduct or poor work performance? Yes No
May we contact this Employer? Yes No
Page 3 of 5
(4) Employer Name:
Address:
Supervisor Name: Telephone No.:
Position(s) Held:
Date Hired: Date Left:
Primary Duties:
Were you terminated for misconduct or poor work performance? Yes No
May we contact this Employer? Yes No
Education
Name of School
Course of Study
Dates Attended
Diploma Degree
High School
XXXXXXXXX
College
College
Trade School/
Other
Page 4 of 5
References
1.
Name:
Phone #:
Address:
Relationship:
2.
Name:
Phone #:
Address:
Relationship:
3.
Name:
Phone #:
Address:
Relationship:
4.
Name:
Phone #:
Address:
Relationship:
By my signature below, I promise that the information provided in this application (and accompanying materials, if any)
is true and complete, and I understand that any false information or significant omissions may disqualify me from
further consideration for employment, and may be justification for my dismissal from the City, if discovered at a later
date. I agree to immediately notify the City if I should be convicted of a felony, or any crime involving dishonesty or a
breach of trust.
I understand that an in-depth background check may be conducted prior to employment with the City of Veneta.
This may include, but is not limited to, a Criminal History check, a DMV check, education and certification
verification, and contact with previous employers and references in order to determine suitability for employment
and ability to qualify for employment with the City of Veneta.
I authorize representatives of the City of Veneta to contact the employers and references listed in this application
(or otherwise provided by me), except as otherwise indicated, and any other person as developed through these
contacts in order to determine my suitability for employment. I understand that as the process progresses I
may be required to provide additional information in order for a thorough background check to be completed.
I understand and agree that, if hired, my employment relationship with the City of Veneta I will be "at-will,"
meaning for no definite period and the relationship may be terminated at any time and without prior notice by
either party.
Applicant's Signature Date
NOTE: NO CONSIDERATION OF EMPLOYMENT WILL BE GIVEN TO ANY APPLICANT WHO DOES
NOT SIGN THE ABOVE STATEMENT.
Please see next page for Veteran’s Preference consideration.
THANK YOU FOR YOUR INTEREST IN EMPLOYMENT WITH THE CITY OF VENETA.
click to sign
signature
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Page 5 of 5
Veterans’ Preference
Name: _________________________________________
FOR OFFICE USE ONLY
Interview? Yes No
Date:
Employed? Yes No
Date:
Department:
Job Title:
Hourly Rate/Salary: $
Approved By:
The following questions are voluntary questions, however, if you are interested in consideration as a
veteran, under Oregon’s veterans’ preference hiring law, we need to know if you qualify. More
information about this law, is available by going to BOLI’s FAQ:
http://www.oregon.gov/boli/TA/t_faq_veterans_preference_2012.aspx
For purposes of veterans’ preference hiring, a veteran is defined as: a person who served on active duty
with the U.S. armed forces for more than 90 consecutive days beginning on or before January 31, 1955
or for more than 178 consecutive days thereafter, and who was discharged or released from such
service under honorable conditions. Also included are veterans who served 178 days or less, but were
discharged or released under honorable conditions because of a service-connected disability (or who
have a disability rating from VA), or who served at least one day in a combat zone and were discharged
or released under honorable conditions. Finally, the veterans’ preference law applies to veterans who
received combat or campaign ribbon or expeditionary medal for service in the U.S. armed forces, and
were discharged or released under honorable conditions.
I meet this definition of a veteran and I am asking for veterans’ preference consideration:
Yes No
For purposes of veterans’ preference hiring, a disabled veteran is a person who has a disability rating
through the U.S. Department of Veterans Affairs, one whose discharge of release was for a disability
incurred or aggravated in the line of duty, or a recipient of the Purple Heart for wounds received in
combat.
I meet this definition of a Disable Veteran and I am asking for veterans’ preference consideration:
Yes No
If you meet the qualifications for Veterans’ Preference consideration, and if you want the City to take this
into consideration as a part of the recruitment process your response must be supported by submission
of form DD-214 or 215.
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In compliance with Federal and State Equal Employment (City of Veneta)

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Completed 17 July 2020

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