Polk Soil and Water ConservaAon District Employment ApplicaAon Form CONTACT: Jackie Has0ngs
RETURN TO:
Email: polk.swcd@oacd.org Office: 503-‐623-‐9680 Fax: 503-‐623-‐3489
Polk SWCD 580 Main Street Suite A Dallas, OR 97338
DirecAons: Applica0ons are accepted only for open posi0ons and must be received no later than noon on the applica0on closing date printed on job announcement. Please make copies of any applica0on materials you wish to keep as copies will not be provided. Postmarks are Not accepted as on-‐0me. Emails and faxes are excepted but the SWCD is not responsible for problems with transmifals. Please print or type in dark ink. This applica0on is only part of the applica0on package. Complete applicaAon includes: Resume, ApplicaAon, Signed Release/Waiver Form, and WriKen Answers to QuesAons. Required documents are listed on the job announcement. POSITION APPLYING FOR:
Date Available
APPLICANT INFORMATION
Name (Last, First, MI)
Home Phone
Street Address
Cell Phone
City, State Zip
Email Address
Driver's License #
State of Issue
EDUCATION Do you have a high school diploma or a GED
Yes No
Year, School, City, State
List All Schools ABended ACer High School (colleges, trade, business, or other special training) School & Loca0on Course of Study/Major Graduate Degree Received Yes
No
Yes
No
Yes
No
Credit Hours Completed
LICENSE/REGISTRATION/CERTIFICATES List any required professional license, registra5on, cer5ficates, Oregon Commercial Driver's License (CDL) etc Descrip0on State Number Expira0on
SPECIALIZED SKILLS AND KNOWLEDGE List skills, knowledge or special training applicable to the posi5on. ABach addi5onal pages as needed.
COMPUTER SOFTWARE
Type of Sokware & Version
PROFICIENCY LEVEL
List specific programs you have used
(i.e. graphic design, ArcView, etc)
Beginner/Intermediate/Advance
EMPLOYEMENT HISTORY Begin with your present or most recent job, list each job, military, and/or volunteer work separately in chronological order. To receive full considera5on fill out the history sec5on completely and legibly. If addi5onal space is needed, you may copy this form and aBach. Resumes must be aBached but are NOT accepted in lieu of comple5ng any sec5on. Name of Employer
Phone Number
Address Job Title FROM (Month-‐Year)
To (Month-‐Year)
May we contact supervisor?
Supervisor Name & Number Hours Worked Per Week Number of Months Worked Yes No Salary per Month
In this job have you supervised any employees? Yes No If Yes, how many DUTEIS (List all du5es and related skills performed. Be specific. If seasonal, list frequency of employment.)
Reason for leaving: Explain Any Gap in Employment Name of Employer Address Job Title FROM (Month-‐Year) To (Month-‐Year)
Phone Number
Supervisor Name & Number Hours Worked Per Week Number of Months Worked May we contact supervisor? Yes No Salary per Month In this job have you supervised any employees? Yes No If Yes, how many DUTEIS (List all du5es and related skills performed. Be specific. If seasonal, list frequency of employment.)
Reason for leaving: Explain Any Gap in Employment Name of Employer Address Job Title FROM (Month-‐Year)
Phone Number
Supervisor Name & Number To (Month-‐Year) Hours Worked Per Week Number of Months Worked May we contact supervisor? Yes No Salary per Month In this job have you supervised any employees? Yes No If Yes, how many DUTEIS (List all du5es and related skills performed. Be specific. If seasonal, list frequency of employment.)
Reason for leaving: Explain Any Gap in Employment Name of Employer Address Job Title FROM (Month-‐Year)
Phone Number
Supervisor Name & Number Hours Worked Per Week Number of Months Worked May we contact supervisor? Yes No Salary per Month In this job have you supervised any employees? Yes No If Yes, how many DUTEIS (List all du5es and related skills performed. Be specific. If seasonal, list frequency of employment.) To (Month-‐Year)
Reason for leaving: Explain Any Gap in Employment Name of Employer Address Job Title FROM (Month-‐Year)
Phone Number
Supervisor Name & Number Hours Worked Per Week Number of Months Worked May we contact supervisor? Yes No Salary per Month In this job have you supervised any employees? Yes No If Yes, how many DUTEIS (List all du5es and related skills performed. Be specific. If seasonal, list frequency of employment.) To (Month-‐Year)
Reason for leaving: Explain Any Gap in Employment Name of Employer Address Job Title FROM (Month-‐Year) To (Month-‐Year)
Phone Number
Supervisor Name & Number Hours Worked Per Week Number of Months Worked May we contact supervisor? Yes No Salary per Month In this job have you supervised any employees? Yes No If Yes, how many DUTEIS (List all du5es and related skills performed. Be specific. If seasonal, list frequency of employment.)
Reason for leaving: Explain Any Gap in Employment Have you ever been discharged or forced to resign?
Yes
No
If Yes, explain
Have you ever been convicted of a Felony?
Yes
No
If Yes, explain
Have you ever been employed by the Polk SWCD?
Yes
No
If Yes, when and 0tle
REFERENCES Name
Rela0onship
Address
Phone
Please Read the Following Before Signing the Applica0on I understand by signing below: ~ All answers and statements on this applica0on are true and complete to the best of my knowledge. ~ Should an inves0ga0on disclose untruthful or misleading answers or omissions, my applica0on may be rejected, my name removed from considera0on or my employment with Polk SWCD terminated. ~ Not every candidate who applied for this posi0on will be offered an interview or to par0cipate in tes0ng. ~ The Polk SWCD will obtain a criminal history background and a driving record check. ~ I hereby authorize Polk SWCD to obtain informa0on from my former employers and others in determining my qualifica0ons and suitability for the posi0on, including informa0on of a confiden0al or privileged nature. I release Polk SWCD from liability that may result from obtaining the informa0on requested for the purpose specified herein. This release will expire one year aker the date it is signed. ~ I understand if my applica0on is incomplete or late, it will be rejected and I will be removed from considera0on. Complete applica0ons will include all required documents listed in job descrip0on (Applica0on, Supplemental Ques0ons, resume, etc).
Applicant's Signature
Date
The Polk SWCD is an Equal Opportunity Employer and does not and will not discriminate in employment and personnel prac=ces on the basis of race, sex, age, handicap, religion, na=onal origin or any other basis prohibited by applicable law.