Fillable Printable EMPLOYMENT APPLICATION - Oregon State Legislature
Fillable Printable EMPLOYMENT APPLICATION - Oregon State Legislature
EMPLOYMENT APPLICATION - Oregon State Legislature
OREGON LEGISLATIVE BRANCH
E
MPLOYMENT
A
PPLICATION
Legislative Administration
Employee Services
900 Court St NE Room 140-B
Salem, Oregon 97301
(503) 986-1373
PER 500 Revised 7/04
1
Legislative OREGON LEGISLATIVE BRANCH
Yes No
Administration
E
MPLOYMENT
Meets MQs
Employee Services
900 Court Street NE Rm 140-B
Salem, Oregon 97301
A
PPLICATION
(503) 986-1373
Fax (503) 986-1684
www.leg.state.or.us
THIS ENTIRE FORM MUST BE PRINTED IN INK OR TYPED-(APPLICATION INFORMATION ON PAGE 5)
Print First
Name:
M.I.
Last
Other Last Names Used
Mailing Address:
Position Applied for:
City, State, Zip Code:
Residence Phone:
Business Phone:
Message Number:
Fax Phone:
Email Address:
Date you could report to work:
Please click on, or write an ‘x’ in, the type(s) of employment that
interest(s) you.
Duration:
Session Continuing Any
Type:
Full Time Any
Limited
Duration
Temporary
Part Time Job Share
EDUCATION AND FORMAL TRAINING
Please list enough education to meet the minimum requirements specified in the recruiting announcement.
Colleges, Military, Trades, Business or Other Schools Attended After High School
Name, Location, Phone Number
Major Course of Study
Total # Credits
Type of Degree
or Certificate Earned
Are you a member of the Oregon State Bar?
Yes No
Bar No.
Do you possess a high school diploma or GED certificate? Yes No
How did you hear about this employment opportunity?
Employment Department JOBLINE
Mailing List
State Agency Friend Newspaper
(Name of Publication)
Job Fair Internet Other
2
VETERANS’ PREFERENCE
PER ORS 408.210-408.235
Veterans may be eligible for veterans’ preference points on scored tests. If you believe you may qualify, you can get
eligibility information from:
a) The Oregon Department of Veterans’ Affairs 1-800-692-9666; or
b) Any Oregon county Veterans’ Services office.
Generally, preference points can be used only once unless you are a disabled veteran. If you were appointed to a permanent position
and went on military leave, you may qualify again for promotional tests only.
Select One.
10 Points
5 Points
Date of Entry (M-D-Y)
Date of Discharge (M-D-Y)
Branch of Service
Receiving Retirement Pay?
Yes No
Theater of Operations
PERSONAL REFERENCES
Name/Title
Address/Telephone Number
LEGISLATIVE EMPLOYMENT HISTORY
Year Position Supervisor
Oregon
Other
This information is not confidential, except as otherwise provided by law.
I understand that employment with the Legislative Branch is employment “At-Will”.
I understand that consideration for employment is contingent on the results of a reference and background check. I authorize
Oregon State Legislature to investigate the truthfulness of all statements made on this application and to contact my former
employers, other listed references, or any other persons who can verify information.
I further authorize Oregon State Legislature to discuss the results of any investigation with all of their employees who are involved
in the hiring process.
I further authorize all contacted persons and former employers to provide information concerning this application, my background
and suitability for employment and I release each person and former employer from liability for providing such information.
I certify that the information contained in this application is correct to the best of my knowledge, and understand that falsifications
and/or omissions in any detail is grounds for disqualification from consideration for employment or if hired, for dismissal from
employment. Unsigned applications will not be considered.
Signature of Applicant
Date
3
WORK EXPERIENCE
Describe your last 4 years of work experience and any other experience required to meet the minimum qualifications for the position
for which you are applying. Include unpaid and volunteer work. Make and attach additional copies of this sheet if necessary.
Employer:
May we contact this employer? Yes
No
Address
:
Supervisor’s Name and Telephone:
Your Title
:
Employed from (month/year) to (month/year)
:
If a supervisor, indicate number of employees and job types supervised:
How long?
Average hours worked per week?
Reason for leaving:
Duties (be specific):
Employer:
May we contact this employer? Yes
No
Address:
Supervisor’s Name and Telephone:
Your Title:
Employed from (month/year) to (month/year):
If a supervisor, indicate number of employees and job types supervised:
How long?
Average hours worked per week?
Reason for leaving:
Duties (be specific):
4
WORK EXPERIENCE
Describe enough work experience to meet the minimum qualifications for the position for which you are applying. Include unpaid
and volunteer work. Attach additional copies of this sheet if necessary.
Employer:
May we contact this employer? Yes
No
Address:
Supervisor’s Name and Telephone:
Your Title:
Employed from (month/year) to (month/year):
If a supervisor, indicate number of employees and job types supervised:
How long?
Average hours worked per week?
Reason for leaving:
Duties (be specific):
Employer:
May we contact this employer? Yes
No
Address:
Supervisor’s Name and Telephone:
Your Title:
Employed from (month/year) to (month/year):
If a supervisor, indicate number of employees and job types supervised:
How long?
Average hours worked per week?
Reason for leaving:
Duties (be specific):
5
GENERAL INFORMATION
Your application must be signed or it will not be
considered. If you submit your application via email, you
may sign your application at the time of your interview.
You must apply for a specific position.
Your application will be considered active for this
position,only.
Read the job announcement carefully before you apply.
Announcements contain specific instructions and
requirements. It is your responsibility to submit all the
required application materials.
Type or print clearly in dark ink. Applications in pencil will
not be accepted. Legible photocopies are acceptable, with
original signatures.
Resumes will not be accepted in lieu of the employment
application form unless stated in specific recruitment.
The Legislature cannot be responsible for material that is
illegible or missing as a result of transmitting by fax or which
may be lost through the mail.
You may be required to verify education and/or self
employment information.
PERSONS WITH DISABILITIES
If you are an applicant with disabilities and need assistance in the
application or interview process, please contact Employee
Services at 986-1373/TTY986-1374.
You do not have to take the test described in a job announcement if
you are severely disabled and you take the following steps:
A) Contact the Oregon Vocational Rehabilitation Division or the
Commission for the Blind to find out if you meet the eligibility
requirements listed in ORS 240.379-394 to qualify for a
“Person with Severe Disability Eligibility Notice.”
B) Review the job announcement to see if you meet the minimum
qualifications for the job as described in the announcement.
C) If you believe you meet the minimum qualifications, follow
the instructions in the job announcement. You must attach a
copy of the “Person with Severe Disability Eligibility Notice -
Part II” (Form R-96-S2) to your application.
AFFIRMATIVE ACTION
This information is voluntary. If you choose to provide this
information, it will help us evaluate the effectiveness of our
affirmative action programs.
The State of Oregon is an equal opportunities and affirmative
action employer.
AFFIRMATIVE ACTION
(VOLUNTARY--
Please click on, or place an
“x” in, the appropriate boxes.)
Gender: Male Female
Ethnicity (read definitions and click on one)
(A)
(B)
(H)
(I)
(W)
ETHNIC DEFINITIONS:
A) Asian or Pacific Islander: Persons having origins in any of
the peoples of the far East, Southeast Asia, the India
subcontinent or the Pacific Islands. This area includes, for
example, China, Japan, Korea, the Philippine Islands and
Samoa.
B) African American (not of Hispanic origin): Persons having
origins in any of the black ethnic groups.
H) Hispanic: Persons having origins in any of the Mexican,
Puerto Rican, Cuban, Central or South American or other
Spanish cultures, regardless of ethnicity.
I) Native American or Alaskan Native: Persons having
origins in any of the original peoples of North America and
who maintain cultural identification through tribal
affiliation or community recognition.
W) Caucasian (not of Hispanic origin): Persons having origin
in any of the original peoples of Europe, North Africa or
the Middle East.
Federal Regulation: The Federal Immigration Reform and
Control Act requires individuals to provide to an employer
documented proof that they are authorized to work in the
United States. This proof must be provided to, and verified by,
state agencies at the time of hire or no later than three business
days after date of hire.
