JobApplication

APPLICATION FOR EMPLOYMENT

CITY OF YAMHILL

P.O. BOX 9

YAMHILL, OR 97148

(503)662-3511

We consider applicants for all positions, without regard to race, color, religion, sex, national origin, age, marital or veteran status, the presence of a non-job related medical condition or handicap, or any other legally protected status.

Date of Application: __________ Position(s) Applied for:___________________________

Referral Source: ________ Advertisement ________ Friend / Relative ________ Walk-In

________ Employment Agency ________ Other

Name: _______________________________________________________________________
Address:______________________________________________________________________
Mailing Address:________________________________________________________________

Telephone #:_______________ Social Security Number:____________________

If employed and you are under 18, can you furnish a work permit: _____Yes _____No

Have you filed an application here before: _____Yes _____No If Yes, give date

Have you ever been employed here before: Yes No If Yes, give date:____________

Are you employed now: __Yes __No May we contact your present employer: ___Yes ___No

Are you prevented from lawfully being employed in this country because of Visa or Immigration Status:

_____Yes _____No (Proof of citizenship or immigration status will be required upon employment)

On what date would you be available for work:__________

Are you available to work: Full Time / Part Time / Shift Work / Temporary

Are you on a lay-off and subject to recall: _____Yes _____No

Can you travel if a job requires it: _____Yes _____No

Have you been convicted of a felony within the last 7 years: _____Yes _____No

(Conviction will not necessarily disqualify applicant from employment)

If yes, please explain:__________________________________________________________

___________________________________________________________________________

AN EQUAL OPPORTUNITY EMPLOYER

Are you a Veteran of the U.S. Military Service: _____Yes _____No If Yes, Branch____________

Indicate languages you speak, read and/or write

	FLUENT	GOOD	FAIR
SPEAK
READ
WRITE

List professional, trade, business or civic activities and offices held:

(You may exclude memberships that would reveal sex, race, religion, national origin, age, ancestry,

or handicap or other protected status): _____________________________________________ ___________________________________________________________________________

___________________________________________________________________________

Give name, address and telephone number of three references who are not related to you and are not

previous employers:

____________________________________________________________________________

____________________________________________________________________________
____________________________________________________________________________

SPECIAL EMPLOYMENT NOTICE TO DISABLED VETERANS, VIETNAM ERA VETERANS

AND INDIVIDUALS WITH PHYSICAL OR MENTAL HANDICAPS:

Government contractors are subject to 38 USC 2012 of the Vietnam Era Veterans Readjustment Act of

1974 which requires that they take affirmative action to employ and advance in employment qualified

disabled veterans of the Vietnam Era, and Section 503 of the Rehabilitation Act of 1973, as amended,

which requires government contractors to take affirmative action to employ and advance in employment

qualified handicapped individuals.

If you are a disabled veteran or have a physical or mental handicap, you are invited to volunteer this

information which will be treated as confidential. Failure to provide this information will not jeopardize

or adversely affect your consideration for employment.

If you wish to be identified, please sign below.

_____Handicapped Individual _____Disabled Veteran _____Vietnam Era Veteran

________________________

Signature

AN EQUAL OPPORTUNITY EMPLOYER

EMPLOYMENT EXPERIENCE

Start with your present or last job. Include military service assignments and volunteer activities. You

may exclude organization names which indicate age, race, color, religion, gender, national origin,

handicap or other protected status.

Employer Name:___________________________________ Employer Phone:_______________
Date of Employement: _______ to _______ Starting Salary __________ Ending Salary _______
Employer Address:_____________________________________________________________
Job Supervisor & Title:____________________ Reason For Leaving:_____________________
Job Duties:____________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

If you need additional space, please continue on a separate sheet of paper.

Special Skills and Qualifications

Summarize special skills and qualifications acquired from employment or other experience:
____________________________________________________________________________
____________________________________________________________________________ ____________________________________________________________________________

EDUCATION:

	Elementary	High School	College/University	Graduate/Professional
School Name
Years Completed
Diploma / Degree
Describe Course of Study
Specialized Training, Apprenticeship, Skills and Extra Curricular Activities.

Honors received/state any additional information you feel may be helpful to us in considering your

application:___________________________________________________________________________

____________________________________________________________________

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APPLICANT'S STATEMENT

I certify that answers given herein are true and complete to the best of my knowledge.

I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

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 period should inquire as to whether or not applications are being accepted at that time.

The applicant understands that neither this document nor any offer of employment from the employer constitute an employment contract unless a specific document to that effect is executed by the employer and employee in writing.

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, also, that I am required to abide by all rules and regulations of the employer.

_____________________________________________ ___________________Date

Signature of Applicant