ࡱ> ܥhc  e?{C<jjjjjjjvBA:+++++29>:)@)@)@;d@ pA |BBX3CHBjy=Pm ++y=y=By=jj+:y=y=y=y=j+j+>͎J`~,jjjjy=>y=vy=STATE OF OREGON EMPLOYMENT APPLICATION An Equal Opportunity Employer TYPE/PRINT IN INKComplete a separate application (photocopy acceptable) for each job unless otherwise specified on the job announcement. If yourapplication is incomplete or does not clearly show you meet the qualifications of the job applied for, your application will not be accepted.SOCIAL SECURITY NUMBER:AFFIRMATIVE ACTION (VOLUNTARY PLEASE CIRCLE) FORMTEXT  GENDER: MALE FEMALEJOB APPLIED FOR (Listed on the job announcement)ETHNICITY (SEE INSTRUCTION PAGE FOR DEFINITIONS AND CIRCLE ONE) FORMTEXT  (A) (B) (H) (I) (W) FORMTEXT CLASS NUMBER:ANNOUNCEMENT NUMBER:DRIVERS LICENSE NUMBER:STATE OF ISSUE: FORMTEXT  FORMTEXT  FORMTEXT  FORMTEXT NAME AND ADDRESSNAME (LAST, FIRST, M.I.):HOME TELEPHONE: FORMTEXT  FORMTEXT MAILING ADDRESS:WORK TELEPHONE: FORMTEXT  FORMTEXT CITY, STATE AND ZIP CODE:MESSAGE (IF DIFFERENT): FORMTEXT  FORMTEXT PRESENT OR LAST EMPLOYER:CITY AND STATE FORMTEXT  FORMTEXT VETERANS PREFERENCE - To Receive Credit Attach a Copy of Your DD214/DD215POINTS: (CIRCLE)DATE OF ENTRY (M-D-Y)DATE OF DISCHARGE (M-D-Y)BRANCH OF SERVICE:AREA OF ARMED CONFLICT 5 10  FORMTEXT  FORMTEXT  FORMTEXT  FORMTEXT WORK SCHEDULECIRCLE ONE:CIRCLE ONE:DATE YOU CAN REPORT FOR WORK: PERMANENT (P) FULL TIME (F) FULL OR PART TIME (E) JOB SHARE (J) FORMTEXT  SEASONAL (S) EITHER (E) PART TIME (P) INTERMITTENT (I) ANY (B) (circle one)Are you also willing to work for the State of Oregon in a temporary position? YES NOGEOGRAPHIC AVAILABILITY - Check up to 40 locations where you are willing to work. If you check too many, the first 40will be recorded. If you check EMA, SMA or PMA, do not check the individual cities within those areas. (Refer to theattached map and geographic availability list for choices). FORMCHECKBOX  EMA FORMCHECKBOX  03G FORMCHECKBOX  05F FORMCHECKBOX  09C FORMCHECKBOX  13A FORMCHECKBOX  16D FORMCHECKBOX  20H FORMCHECKBOX  23E FORMCHECKBOX  27A FORMCHECKBOX  32D FORMCHECKBOX  SMA FORMCHECKBOX  03H FORMCHECKBOX  06A FORMCHECKBOX  09D FORMCHECKBOX  13E FORMCHECKBOX  17A FORMCHECKBOX  20I FORMCHECKBOX  24C FORMCHECKBOX  27D FORMCHECKBOX  33G FORMCHECKBOX  PMA FORMCHECKBOX  03I FORMCHECKBOX  06B FORMCHECKBOX  09E FORMCHECKBOX  14A FORMCHECKBOX  17B FORMCHECKBOX  20J FORMCHECKBOX  24L FORMCHECKBOX  28C FORMCHECKBOX  34A FORMCHECKBOX  03K FORMCHECKBOX  06C FORMCHECKBOX  10A FORMCHECKBOX  14B FORMCHECKBOX  18B FORMCHECKBOX  21A FORMCHECKBOX  24M FORMCHECKBOX  29D FORMCHECKBOX  34B FORMCHECKBOX  01A FORMCHECKBOX  03L FORMCHECKBOX  06H FORMCHECKBOX  10C FORMCHECKBOX  14C FORMCHECKBOX  18C FORMCHECKBOX  21B FORMCHECKBOX  24P FORMCHECKBOX  29F FORMCHECKBOX  34D FORMCHECKBOX  01F FORMCHECKBOX  03M FORMCHECKBOX  06J FORMCHECKBOX  10G FORMCHECKBOX  15A FORMCHECKBOX  18E FORMCHECKBOX  21D FORMCHECKBOX  24Q FORMCHECKBOX  30F FORMCHECKBOX  34F FORMCHECKBOX  01J FORMCHECKBOX  03N FORMCHECKBOX  06K FORMCHECKBOX  10I FORMCHECKBOX  15C FORMCHECKBOX  18F FORMCHECKBOX  21F FORMCHECKBOX  24S FORMCHECKBOX  30G FORMCHECKBOX  34H FORMCHECKBOX  02A FORMCHECKBOX  04A FORMCHECKBOX  07A FORMCHECKBOX  10J FORMCHECKBOX  15E FORMCHECKBOX  19A FORMCHECKBOX  21G FORMCHECKBOX  25A FORMCHECKBOX  30H FORMCHECKBOX  34I FORMCHECKBOX  02C FORMCHECKBOX  04C FORMCHECKBOX  08A FORMCHECKBOX  11A FORMCHECKBOX  15G FORMCHECKBOX  19D FORMCHECKBOX  22A FORMCHECKBOX  25C FORMCHECKBOX  30K FORMCHECKBOX  34J FORMCHECKBOX  03C FORMCHECKBOX  04D FORMCHECKBOX  08B FORMCHECKBOX  11B FORMCHECKBOX  15K FORMCHECKBOX  20B FORMCHECKBOX  22E FORMCHECKBOX  26B FORMCHECKBOX  30M FORMCHECKBOX  35A FORMCHECKBOX  03D FORMCHECKBOX  04E  FORMCHECKBOX  18B FORMCHECKBOX  08C FORMCHECKBOX  12B FORMCHECKBOX  15L FORMCHECKBOX  20D FORMCHECKBOX  22H FORMCHECKBOX  26C FORMCHECKBOX  31E FORMCHECKBOX  36F FORMCHECKBOX  03E FORMCHECKBOX  05A FORMCHECKBOX  09A FORMCHECKBOX  12E FORMCHECKBOX  16A FORMCHECKBOX  20E FORMCHECKBOX  22J FORMCHECKBOX  26D FORMCHECKBOX  32A FORMCHECKBOX  36G FORMCHECKBOX  03F FORMCHECKBOX  05B FORMCHECKBOX  09B FORMCHECKBOX  12G FORMCHECKBOX  16B FORMCHECKBOX  20G FORMCHECKBOX  23D FORMCHECKBOX  26F FORMCHECKBOX  32B FORMCHECKBOX OTHEROFFICE USE ONLYSkill Codes:___ Accepted (Instructions Enclosed)___ NOT ACCEPTED _______________(Reason Code) Reviewers Initials / DateORIGINAL TEST DATE:TEST DATE:EXPIRATION DATE:ORIGINAL BATCH CODE:TEST NUMBERRAW SCOREV.P.S.C.FINAL123456                         EDUCATION / TRAINING HISTORYDo you have a high school diploma or a GED certificate? (CIRCLE ONE) YES NOList colleges, military, trade, business or other schools attended.Course of StudyCredits EarnedGraduatedType of DegreeName and Location of School(List Major)ClockQtr.Sem.(Yes / No)or CertificatehourshourshoursReceivedA FORMTEXT  FORMTEXT  FORMTEXT  FORMTEXT  FORMTEXT  FORMTEXT  FORMTEXT B FORMTEXT  FORMTEXT  FORMTEXT  FORMTEXT  FORMTEXT  FORMTEXT  FORMTEXT C FORMTEXT  FORMTEXT  FORMTEXT  FORMTEXT  FORMTEXT  FORMTEXT  FORMTEXT LICENSE / REGISTRATION / CERTIFICATEList any required professional license, registration, certificate, Oregon Commercial Drivers License (CDL), etc.DescriptionStateNumberExpiration FORMTEXT  FORMTEXT  FORMTEXT  FORMTEXT  FORMTEXT  FORMTEXT  FORMTEXT  FORMTEXT SPECIALIZED SKILLS AND KNOWLEDGEList any skills or knowledge that show your ability to perform the job for which you are applying,(such as typing speed, computer languages or software programs, foreign languages, etc.) FORMTEXT LIST YOUR LAST FOUR EMPLOYERS FOR EMPLOYMENT VERIFICATION PURPOSESCURRENT OR LAST EMPLOYERS NAME ADDRESS AND PHONE NUMBER: FORMTEXT KIND OF BUSINESSYOUR JOB TITLE(1)  FORMTEXT  FORMTEXT SUPERVISORS NAME AND PHONE NUMBER FORMTEXT FROM (MONTH - YEAR)TO (MONTH - YEAR) FORMTEXT  FORMTEXT EMPLOYERS NAME ADDRESS AND PHONE NUMBER: FORMTEXT KIND OF BUSINESSYOUR JOB TITLE(2)  FORMTEXT  FORMTEXT SUPERVISORS NAME AND PHONE NUMBER FORMTEXT FROM (MONTH - YEAR)TO (MONTH - YEAR) FORMTEXT  FORMTEXT EMPLOYERS NAME ADDRESS AND PHONE NUMBER: FORMTEXT KIND OF BUSINESSYOUR JOB TITLE(3)  FORMTEXT  FORMTEXT SUPERVISORS NAME AND PHONE NUMBER FORMTEXT FROM (MONTH - YEAR)TO (MONTH - YEAR) FORMTEXT  FORMTEXT EMPLOYERS NAME ADDRESS AND PHONE NUMBER:  FORMTEXT  KIND OF BUSINESSYOUR JOB TITLE(4)  FORMTEXT  FORMTEXT SUPERVISORS NAME AND PHONE NUMBER  FORMTEXT  FROM (MONTH - YEAR)TO (MONTH - YEAR) FORMTEXT  FORMTEXT PAGE 2 WORK HISTORY ((( A RESUME WILL NOT SUBSTITUTE What you write in this section will be used to decide if you meet the To Qualify section of the job announcement. List ONLY the job(s) (paid or volunteer) where you got experience that qualifies you for the job you are applying for. Clearly describe all of your duties, starting with your most recent job. If the qualifying experience shown on the job announcement is not the main duty, but only part of the duties you performed in a job you are listing, you must include the percentage of time actually spent on the qualifying experience. For example, performing bookkeeping duties 4 hours of a 40 hour week = 10%; or 5hours of a 20 hour week = 25%. Credit for work that is less than full-time is pro-rated based on a 40 hour week. Complete each box. If you do not provide all the information required in this section, no credit will be given for that job. If you need additional space to list job duties, attach a separate sheet; clearly identify the job youre describing. Copy this page if you need to list more jobs. (Be sure to identify additional jobs by numbering them 5,6,7 etc.) JOB NUMBER 1:NAME OF EMPLOYEREMPLOYERS ADDRESS AND PHONE NUMBER FORMTEXT  FORMTEXT KIND OF BUSINESSSUPERVISORS NAME AND PHONE NUMBER FORMTEXT  FORMTEXT YOUR JOB TITLESUPERVISION / LEADWORK CHECK THE AREAS YOU WERE RESPONSIBLE FOR: FORMTEXT   FORMCHECKBOX  Assigning and Reviewing work  FORMCHECKBOX  Handling Disciplinary problemsFROM (MONTH - YEAR)TO (MONTH - YEAR)  FORMCHECKBOX  Rating Work Performance  FORMCHECKBOX  Responding to Grievances FORMTEXT  FORMTEXT   FORMCHECKBOX  Hiring or Recommending Hiring  FORMCHECKBOX  Not Responsible for Any of AboveTOTAL TIME IN CURRENT ORHOURS WORKED PER WEEKLIST THE NUMBER OF EMPLOYEES YOU SUPERVISED AND LIST THEIR JOB TYPE:LAST POSITION:(AVERAGE)  FORMTEXT  FORMTEXT   FORMTEXT DUTIES (List all duties you performed. No credit will be given if this section is not completed.):  FORMTEXT JOB NUMBER 2:NAME OF EMPLOYEREMPLOYERS ADDRESS AND PHONE NUMBER FORMTEXT  FORMTEXT KIND OF BUSINESSSUPERVISORS NAME AND PHONE NUMBER FORMTEXT  FORMTEXT YOUR JOB TITLESUPERVISION / LEADWORK CHECK THE AREAS YOU WERE RESPONSIBLE FOR: FORMTEXT   FORMCHECKBOX  Assigning and Reviewing work  FORMCHECKBOX  Handling Disciplinary problemsFROM (MONTH - YEAR)TO (MONTH - YEAR)  FORMCHECKBOX  Rating Work Performance  FORMCHECKBOX  Responding to Grievances FORMTEXT  FORMTEXT   FORMCHECKBOX  Hiring or Recommending Hiring  FORMCHECKBOX  Not Responsible for Any of AboveTOTAL TIME IN POSITIONHOURS WORKED PER WEEKLIST THE NUMBER OF EMPLOYEES YOU SUPERVISED AND LIST THEIR JOB TYPE::(AVERAGE)  FORMTEXT   FORMTEXT   FORMTEXT DUTIES (List all duties you performed. No credit will be given if this section is not completed.):  FORMTEXT CONTINUE WORK EXPERIENCE ON NEXT PAGE ( YOUR APPLICATION MUST BE RECEIVED AT THE ADDRESS LISTED ON THE JOB ANNOUNCEMENT BY THE CLOSE DATE (PAGE 3 JOB NUMBER 3:NAME OF EMPLOYEREMPLOYERS ADDRESS AND PHONE NUMBER FORMTEXT  FORMTEXT KIND OF BUSINESSSUPERVISORS NAME AND PHONE NUMBER FORMTEXT  FORMTEXT YOUR JOB TITLESUPERVISION / LEADWORK CHECK THE AREAS YOU WERE RESPONSIBLE FOR: FORMTEXT   FORMCHECKBOX  Assigning and Reviewing work  FORMCHECKBOX  Handling Disciplinary problemsFROM (MONTH - YEAR)TO (MONTH - YEAR)  FORMCHECKBOX  Rating Work Performance  FORMCHECKBOX  Responding to Grievances FORMTEXT  FORMTEXT   FORMCHECKBOX  Hiring or Recommending Hiring  FORMCHECKBOX  Not Responsible for Any of AboveTOTAL TIME IN POSITIONHOURS WORKED PER WEEKLIST THE NUMBER OF EMPLOYEES YOU SUPERVISED AND LIST THEIR JOB TYPE::(AVERAGE)  FORMTEXT  FORMTEXT   FORMTEXT DUTIES (List all duties you performed. No credit will be given if this section is not completed.):  FORMTEXT JOB NUMBER 4:NAME OF EMPLOYEREMPLOYERS ADDRESS AND PHONE NUMBER FORMTEXT  FORMTEXT KIND OF BUSINESSSUPERVISORS NAME AND PHONE NUMBER FORMTEXT  FORMTEXT YOUR JOB TITLESUPERVISION / LEADWORK CHECK THE AREAS YOU WERE RESPONSIBLE FOR: FORMTEXT   FORMCHECKBOX  Assigning and Reviewing work  FORMCHECKBOX  Handling Disciplinary problemsFROM (MONTH - YEAR)TO (MONTH - YEAR)  FORMCHECKBOX  Rating Work Performance  FORMCHECKBOX  Responding to Grievances FORMTEXT  FORMTEXT   FORMCHECKBOX  Hiring or Recommending Hiring  FORMCHECKBOX  Not Responsible for Any of AboveTOTAL TIME IN POSITIONHOURS WORKED PER WEEKLIST THE NUMBER OF EMPLOYEES YOU SUPERVISED AND LIST THEIR JOB TYPE::(AVERAGE)  FORMTEXT   FORMTEXT   FORMTEXT DUTIES (List all duties you performed. No credit will be given if this section is not completed.):  FORMTEXT HOW DID YOU LEARN ABOUT THIS POSITION?  FORMCHECKBOX  Newspaper (List Publication)  FORMCHECKBOX  Employment Office  FORMCHECKBOX  Jobline  FORMCHECKBOX  Friend  FORMCHECKBOX  State Agency or State EmployeeCERTIFICATION AND SIGNATUREI understand that any oral or written statement that is false, fraudulent or misleading that is contained in this application or attached materials, or made in the course of any related employment process, whether made by me or by others at my request, will result in rejection of my application, denial of employment, or dismissal from state service if discovered after employment, and in many circumstances, prosecution for a crime. I certify that all statements contained herein are true and complete whether made by me or others at my request. I understand that I must prove that I am authorized to work in the United States if I am hired. I authorize the employing agency to verify the employment and education information provided on this employment application. I authorize my driving record be checked if the position for which I am applying requires driving. I understand and agree to be subjected to a pre-employment drug screening and a criminal history background check, if applicable.SIGNATURE (MUST BE IN INK)DATEKEEP A COPY OF YOUR APPLICATION FOR INTERVIEWS(COPIES WILL NOT BE PROVIDEDPAGE 4 /=@@RU:Text1TERU:Text2E)U:Text3LICU:Text4U:Text5OR U:Text6 U:Text7) U:Text8 V:Text11 U:Text9 V:Text12ilV:Text10EOV:Text13chV:Text14ckV:Text15avV:Text16BOV:Text17BOV:Text18KBV:Text19KBV:Text20KBV:eCheck1CKW:eCheck13KW:eCheck26EW:eCheck39EW:eCheck52EW:eCheck65HW:eCheck78HW:eCheck91CX:eCheck104X:eCheck121V:eCheck2RMW:eCheck14MW:eCheck27RW:eCheck40RW:eCheck54RW:eCheck66OW:eCheck79OW:eCheck92FX:eCheck105X:eCheck122V:eCheck3 W:eCheck16 W:eCheck28W:eCheck41W:eCheck53W:eCheck67W:eCheck81W:eCheck93RX:eCheck106X:eCheck123W:eCheck15OW:eCheck29W:eCheck43 W:eCheck55eW:eCheck68fW:eCheck80cW:eCheck94TX:eCheck107X:eCheck124V:eCheck4TEW:eCheck17W:eCheck30eW:eCheck42tW:eCheck56TW:eCheck69W:eCheck82eW:eCheck95iX:eCheck108X:eCheck124V:eCheck5SSW:eCheck18HW:eCheck31W:eCheck44W:eCheck57SW:eCheck70W:eCheck83OW:eCheck96X:eCheck109X:eCheck125V:eCheck7W:eCheck20OW:eCheck32 W:eCheck45eW:eCheck58 W:eCheck71aW:eCheck84bW:eCheck97oX:eCheck110X:eCheck126V:eCheck6edW:eCheck19eW:eCheck33wW:eCheck46eW:eCheck59oW:eCheck72OW:eCheck85W:eCheck98X:eCheck111X:eCheck127V:eCheck8R)W:eCheck21OW:eCheck35FW:eCheck47sW:eCheck60OW:eCheck74TW:eCheck86fW:eCheck99X:eCheck112X:eCheck128V:eCheck9OUW:eCheck22iW:eCheck34AW:eCheck48 W:eCheck61W:eCheck73oW:eCheck87OX:eCheck100X:eCheck113X:eCheck120W:eCheck11 W:eCheck24EW:eCheck23TW:eCheck37W:eCheck49SW:eCheck62 W:eCheck75OW:eCheck88KX:eCheck101X:eCheck114X:eCheck119W:eCheck10XW:eCheck24 W:eCheck36OW:eCheck50W:eCheck63W:eCheck76:W:eCheck89FX:eCheck102X:eCheck115X:eCheck118W:eCheck12oW:eCheck25VW:eCheck38W:eCheck51tW:eCheck64IW:eCheck77 W:eCheck90yX:eCheck103X:eCheck116X:eCheck117V:Text90inV:Text91loW:Text107oV:Text93afW:Text108sV:Text95quV:Text96ifV:Text99nfW:Text100kW:Text101bW:Text102 W:Text103TW:Text104W:Text105V:Text28V:Text29V:Text30V:Text31V:Text32V:Text33V:Text34V:Text42V:Text43V:Text44V:Text45V:Text46V:Text47V:Text48V:Text49V:Text50V:Text51V:Text52V:Text53V:Text54V:Text55V:Text56V:Text57V:Text58V:Text59V:Text60V:Text61V:Text62V:Text63V:Text64V:Text65W:Text106W:Text109W:Text110V:Text63V:Text64V:Text65W:Text106W:Text111W:Text112V:Text68V:Text69V:Text70V:Text71V:Text72V:eCheck1V:eCheck2V:eCheck3V:eCheck5V:Text73V:Text74V:eCheck4V:eCheck6V:Text75V:Text76V:Text77V:Text78V:Text79V:Text80V:Text81V:Text82V:Text83V:eCheck1V:eCheck2V:eCheck3V:eCheck5V:Text84V:Text85V:eCheck4V:eCheck6V:Text86V:Text87V:Text88V:Text89V:Text68V:Text69V:Text70V:Text71V:Text72V:eCheck1V:eCheck2V:eCheck3V:eCheck5V:Text73V:Text74V:eCheck4V:eCheck6V:Text75V:Text76V:Text77V:Text78V:Text79V:Text80V:Text81V:Text82V:Text83V:eCheck1V:eCheck2V:eCheck3P:eV:Text84FV:Text85sV:eCheck4OV:eCheck6TV:Text86fV:Text87V:Text88V:Text89P:eP:eP:eP:eP:e'DEVg~)*jklvw~TU_`ghist{|}uD|AC]GuD$AC]GuD@C]GuDt@C]GuD@C]GU]c]cuD?C]G uD]]c]bc U]bc]c U]bc] UV]cU]c< 245?@GIJTU\]_  bcuDDC]GuDDC]GuD #$%*+9:;@AOPQVWefglm{|}uD$LC]GuDKC]GuDtKC]GuDKC]GuDJC]GuDlJC]GuDJC]GuDIC]GuDdIC]GuD IC]GuDHC]G] uD]uD\HC]G;,-.34BCDIJXYZ_`nopuvuDDPC]GuDOC]GuDOC]GuDLMNSTbcdjkyz{uDdTC]GuD TC]GuDSC]GuD\SC]GuDSC]GuDRC]GuDTRC]GuDQC]GuDQC]GuDLQC]GuDPC]GuDPC]G] uD];)*+01?@AGHVWX]^lmnstuDXC]GuD,XC]GuDWC]GuD|WC]GuD$WC]GuDVC]GuDtVC]GuDVC]GuDUC]GuDlUC]GuDUC]GuDTC]G uD]]; 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