| Personal Information |
| Position you are applying for: |
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| Today's Date: |
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| Social Security Number: |
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| Street Address: |
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| Home Telephone: |
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| Business Telephone: |
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| E-mail Address: |
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| City: |
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| State: |
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| Zip Code: |
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| Have you applied at the Columbia Gorge Center before ? |
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| If yes what date(s) and position(s)? |
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| Are you presently on layoff and subject to recall? |
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| Are you available for full-time work? |
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| If no, what days can you work? |
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| Are you legally eligible for United States employment? |
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| If hired, when can you start working for us? |
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| Will you work overtime if asked? |
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| Are you between the ages of 18 and 70? |
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| Do you have a valid driver's license? |
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Have you been convicted of any crimes in the past 10 years, excluding misdemeanors and summary offenses, which have been annulled, expunged, or sealed by a court? If yes describe in detail:
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| Education |
| Did you graduate from high school? |
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| If no, how many years did you complete? |
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| Which high school did you attend (name and location)? |
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| Did you attend a business/trade school? |
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| If yes, which business/trade school did you attend (name and location)? |
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| What did you study at the business/trade school? |
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| How many business/trade school years did you complete? |
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| What business/trade school certificate did you receive? |
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| Did you attend college? |
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| If yes, which college did you attend (name and location)? |
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| What did you major in while attending college? |
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| What did you minor in while attending college? |
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| How may college years did you complete? |
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| What degree did you receive? |
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| Current Memberships in Professional or Community Organizations |
| Exclude those which may disclose your race, color, religion, or national origin. |
| Organization: |
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| Membership Activities: |
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| How long have you been a member? |
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| Organization: |
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| Membership Activities: |
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| How long have you been a member? |
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| Organization: |
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| Membership Activities: |
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| How long have you been a member? |
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| Employment History |
| Start with your present or most recent employer. Give accurate, complete full-time and part-time employment history. |
| Company Name: |
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| Telephone Number: |
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| Month and Year Employment Began: |
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| Month and Year Employment Ended: |
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| Supervisor's Name: |
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| Starting Monthly Gross Wage: |
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| Ending Monthly Gross Wage: |
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| Job Title: |
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| Description of Duties: |
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| Reason for Leaving: |
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| Company Name: |
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| Telephone Number: |
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| Address: |
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| Month and Year Employment Began: |
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| Month and Year Employment Ended: |
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| Supervisor's Name: |
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| Starting Monthly Gross Wage: |
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| Ending Monthly Gross Wage: |
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| Job Title: |
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| Description of Duties: |
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| Reason for Leaving: |
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| Company Name: |
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| Telephone Number: |
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| Address: |
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| Month and Year Employment Began: |
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| Month and Year Employment Ended: |
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| Supervisor's Name: |
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| Starting Monthly Gross Wage: |
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| Ending Monthly Gross Wage: |
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| Job Title: |
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| Description of Duties: |
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| Reason for Leaving: |
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| Company Name: |
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| Telephone Number: |
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| Address: |
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| Month and Year Employment Began: |
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| Month and Year Employment Ended: |
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| Supervisor's Name: |
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| Starting Monthly Gross Wage: |
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| Ending Monthly Gross Wage: |
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| Job Title: |
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| Description of Duties: |
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| Reason for Leaving: |
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Applicant's Initials
I hereby expressly permit Columbia Gorge Center to contact the above employers, except the following:
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| Volunteer History |
| Organization Name: |
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| Location: |
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| Month and Year Volunteer Service Began: |
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| Month and Year Volunteer Service Ended: |
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| Service(s) Provided by Organization: |
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| Your Volunteer Service(s) Consisted of : |
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| Organization Name: |
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| Location: |
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| Month and Year Volunteer Service Ended: |
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| Service(s) Provided by Organization: |
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| Your Volunteer Service(s) Consisted of: |
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| Skills, Experience, and Qualifications |
Please list any skills, experience, or qualifications you believe will be valuable to our organization.
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| References |
| List your professional references (other than former employers or relatives). |
| Name: |
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| Telephone Number: |
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| Address: |
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| Occupation: |
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| Length of Time Known: |
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| Name: |
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| Telephone Number: |
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| Address: |
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| Occupation: |
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| Length of Time Known: |
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| Name: |
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| Telephone Number: |
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| Address: |
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| Occupation: |
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| Length of Time Known: |
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| Please Read and Understand the Following Statement Before Submitting Your Application: |
The information I provided in this Application for Employment is true, correct, and complete. False, incomplete, or misrepresented information of any kind will be sufficient cause for my application to be rejected or, if discovered after I am employed, will cause immediate termination of my employment.
I authorize Columbia Gorge Center to contact and obtain information about me from previous employers, educational institutions and references I provided, and any other party necessary to verify the accuracy of information I disclosed in this application, related employment resume, or personal interview. To assist in the processing of my application, I waive all rights and claims I may otherwise have against Columbia Gorge Center or its representatives for seeking and using information to evaluate my employment request and all other persons, corporations, or organizations who provide information for this purpose.
This application will expire in 30 days from the date submitted. After that date, unless otherwise notified, my status as an applicant will end. I may reapply for employment in the future by completing a new application.
This application is not an employment agreement. If I accept an offer of employment I understand the employer may terminate my employment at any time, with or without cause and without prior notice unless required by law. I understand that no manger or representative of Columbia Gorge Center, other than the Board of Directors, has any authority to enter into any agreement for any specified period of time or to make any agreement contrary to the foregoing, and such agreement must be in writing.
Management will make an effort to accommodate individual preferences. However, business needs may make the following conditions mandatory: overtime, shift work, a rotating work schedule, or a work schedule other than Monday through Friday. I understand and accept the above as conditions of my continuing employment.
Yes or No:
Applicant's Signature:
Date Signed:
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| Employment Reference Check |
| Supervisors must list a minimum of three employment references contacted. If applicant has fewer than three former employers, contact professional references. |
| Employer: |
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| Telephone Number: |
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| Contact Date: |
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| Individual Providing Reference: |
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| Relationship to Applicant: |
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| Results: |
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| Telephone Number: |
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| Contact Date: |
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| Individual Providing Reference: |
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| Relationship to Applicant: |
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| Results: |
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| Employer: |
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| Telephone Number: |
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| Contact Date: |
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| Individual Providing Reference: |
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| Relationship to Applicant: |
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| Results: |
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| Employer: |
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| Telephone Number: |
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| Contact Date: |
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| Individual Providing Reference: |
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| Relationship to Applicant: |
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| Results: |
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| Addendum to Application for Employment |
| Equal Employment Opportunity Information |
Columbia Gorge Center promotes the employment of people with disabilities. This form is designed to assist us in that effort. We are also required by state and federal laws and regulations to furnish statistical data on all job applicants. We would appreciate your cooperation in providing us with the required information below.
Columbia Gorge Center is an equal opportunity employer. This information will be used for statistical purposes only. The information is voluntary, and failure to provide it will not affect hiring decisions. It will be separated from your application form and will be kept in a confidential file.
Initial here
if you choose not to disclose the information requested in the section below.
Your Name:
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| Male
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| Female
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| African-American
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| Asian/Pacific Islander
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| Native American
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| Alaskan Native
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| Hispanic
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| Caucasian
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| Vietnam Era Veteran (who has served more than 180 days of active duty between 08/05/64 and 05/07/75)
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| Disabled Veteran* (entitled to disability compensation by the Veterans' Administration for a disability rated at 30 percent or more whose discharge was for a disability incurred in the line of duty)
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| A person with a disability* who (1) has a physical or mental impairment which substantially limits one or more of the individual's major life activities; (2) has a record of the impairment; or (3) is regarded as having such an impairment. (The person is "substantially limited" if he or she is likely to experience difficulty in securing, retaining, or advancing in employment because of a disability.)
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| For Office Use Only |
| Employment Application Date:
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| Applicant Hired; completed and signed application: Dept:
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| Start Date:
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| Starting Wage:
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Applicant Not Hired:
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