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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. |
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Position(s) applied for: Today's Date:
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Last Name:
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First Name:
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Middle Name:
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Email Address:
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Address:
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City:
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State:
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Zip Code:
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Telephone number:
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Social Security Number: |
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Do you
meet the qualifications on the job
announcement as attached to this
application? |
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Have you ever filed an
application with us before? |
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Have you ever been
employed by us before? |
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Are you currently
employed? |
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Are you currently on
"lay-off" status and subject to recall? |
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May we contact your
present employer? |
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Check the following
options you would consider. |
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| Full Time
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Part Time |
Shift Work |
Temp
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Date available
for work: |
Wages desired: |
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Can you travel if a job
requires it? |
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Have you been convicted
of a felony within the past 7 years? |
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If yes, please explain
below. (Criminal Background Checks will
be completed on every person hired at
Rockwest in accordance with ORS 181.537) |
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IN CASE OF EMERGENCY, CONTACT: |
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Name: |
Phone: |
Other phone: |
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ROCKWEST IS A DRUG-FREE WORKPLACE |
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EDUCATION |
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| Name/location of High School: |
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| Number of years completed: |
Course of study: |
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| Did you graduate? |
Diploma or degree: |
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| Name/location of college: |
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| Number of years completed: |
Course of study: |
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| Did you graduate? |
Diploma or degree: |
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| Name/location of Trade School: |
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| Number of years completed: |
Course of study: |
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| Did you graduate? |
Diploma or degree: |
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| Describe any specialized training, apprenticeship, skills and extra-curricular activities. |
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REFERENCES |
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| Reference 1 |
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| Name and Address: |
Relationship: |
| How long have you known him/her? |
Telephone number: |
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| Reference 2 |
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| Name and address: |
Relationship: |
| How long have you known him/her? |
Telephone number: |
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| Reference 3 |
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| Name and address: |
Relationship: |
| How long have you known him/her? |
Telephone number: |
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| Reference 4 |
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| Name and address: |
Relationship: |
| How long have you known him/her? |
Telephone number: |
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| Reference 5 |
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| Name and address: |
Relationship: |
| How long have you known him/her? |
Telephone number: |
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EMPLOYMENT EXPERIENCE - LIST MOST RECENT EMPLOYMENT FIRST |
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Job #1 |
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| From: To: |
Company name and address: |
| Telephone number: |
Last position held: |
Last wages: |
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| Work performed: |
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| Supervisors name: |
Supervisors title: |
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| Reason for leaving: |
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| Job #2 |
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| From: To: |
Company Name and Address: |
| Telephone Number: |
Last position held: |
Last Wages: |
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| Work performed: |
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| Supervisors name: |
Supervisors title: |
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| Reason for leaving: |
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| Job #3 |
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| From: To: |
Company name and address: |
| Telephone number: |
Last position held: |
Last wages: |
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| Work performed: |
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| Supervisors name: |
Supervisors title: |
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| Reason for leaving: |
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| Job #4 |
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| From: To: |
Company name and address: |
| Telephone number: |
Last position held: |
Last wages: |
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| Work performed: |
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| Supervisors name: |
Supervisors title: |
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| Reason for leaving: |
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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 |
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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 |
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REFERENCE CHECKS 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 |
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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 |
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