OCP Application – Oregon Community Programs

Work Experience - Step 1 of 8

Date *

Position applying for *

How did you hear about this position? *

How many hours a week are you hoping to work? *

Are you bilingual in English/Spanish? *

Name *

First

Last

Phone *

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Date Available

Please list Institution Name, Address, Major area of specialization and Degree

Company Name

Is this your current employer?

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Supervisor

Can we contact this employer?

Specific duties performed

Hours worked per week:

Dates Employed

Reason for leaving

Company Name

Is this your current employer?

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Supervisor

Can we contact this employer?

Specific duties performed

Hours worked per week:

Dates Employed

Reason for leaving

Company Name

Is this your current employer?

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Supervisor

Can we contact this employer?

Specific duties performed

Dates Employed

Hours worked per week:

Reason for leaving

Please describe your reasons for seeking this position and why you feel you are qualified for this job.

If you have any skills, interests, or experience that may be complementary to this position, please mention them.

PLEASE READ PRIOR TO COMPLETING AND SIGNING THIS APPLICATION.

1. This company is an equal employment opportunity employer and does not discriminate because of age, sex, race, creed, color, national origin, disability, sexual orientation, citizenship status, or religious preference.

2. Proof of employment eligibility for compliance with the United States Immigration Control and Reform Act of 1986 is required prior to employment.

3. I understand that, if the position applied for requires frequent driving, I must comply with certain automobile liability insurance requirements and provide proof of insurance, if hired.

4. All positions require a criminal records check.

5. Documentation of required credentials must be received prior to final interview.

6. I hereby authorize and request any and all of my former employers to furnish any and all information concerning my job performance. I agree to hold my former employers and their agents harmless from all liability which could relate in any way to the disclosure of private information or an assessment or opinion of my suitability for employment.

7. I have read and understand the job description. I have no physical or mental requirements or limitations which might affect my ability to perform the job.

8. I understand that misrepresentation or omission of facts herein is cause for termination, if I am hired.

9. I understand that, if hired, I will be required to: 1) Sign a Confidentiality Agreement, requiring me to refrain from disclosing client or research participation information, and 2) Complete required HIPAA training.

10. I have read and understand this application and have answered all portions of this application truthfully and correctly, with no omissions.

This application is valid for 90 days.

Date of Application *

Electronic Signature *

Please type your name

Checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Disclaimer. *

Choice 1

Name *

First

Last

I hereby authorize the employer(s) / references listed below to release information regarding my employment, including information about my performance, compensation, employment dates, and other relevant circumstances to Oregon Community Programs. Should you be considered for this position, the references listed on this page will be contacted. Please make sure that all contact information is current. *

Name of Organization

Reference 1 of 3

Name and Position of Supervisor or Reference

Phone *

Your Position

Name of Organization

Reference 2 of 3

Name and Position of Supervisor or Reference

Phone *

Your Position

Name of Organization

Reference 3 of 3

Name and Position of Supervisor or Reference

Phone *

Your Position

Electronic Signature *

Please type your name

Checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Disclaimer. *

Choice 1

Date *

Please upload your cover letter and resume *

Click or drag files to this area to upload. You can upload up to 3 files.

Allowed formats: PDF, DOCX or DOC

Name