Polk Soil and Water Conservation District Employment Application Form Position Applying For: _______________________________________________ Please print or type in dark ink. This application is part of the applicant examination process and must be thoroughly completed in order to be considered. If you need additional space attach a separate sheet. We strongly suggest you keep a copy of your completed application.
APPLICANT INFORMATION NAME (Last, First, Middle)
Name Called By
Date Application Completed
Street Address
Years at this Address
Driver’s License # & State
Mailing Address
City
State
Home Phone
Cell Phone
Present Employer Last Employer (Check one)
Have you been employed previously by Polk SWCD? Do you have the legal right to work permanently in the U.S.? Are you 18 years of age or over? Have you been convicted of a Felony? Have you ever been convicted of a misdemeanor involving dishonesty or fraud? Have you ever been discharged or forced to resign from any
Email Address May we contact? Yes No
Phone Number
If yes, when and what position YES
NO If no, please explain
YES
NO
YES
NO
YES
NO
If no, please explain If yes, please explain
If yes, please explain YES
NO
If yes, please explain YES
NO
employment? EQUAL OPPORTUNITY EMPLOYER
Zip
Relatives or acquaintance employed by Polk SWCD
Name
Relationship Department
Highest year education completed: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Graduated from High School? Name of High School: Location of High School: Yes No GED? Yes No Name & Location Major Check Last Dates Graduate? Degree Received of Additional Subjects Year Attended Yes / No (Type) School, College, or Studied Completed University 1 2 3 4 1 2 3 4 1 2 3 4 Additional Courses or Graduate Studies
LICENSE / REGISTRATION / CERTIFICATES List any required professional license, registration, certificate, Oregon Commercial Driver’s License (CDL), etc. Description State Number Expiation
SPECIALIZED SKILLS AND KNOWLEDGE List 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.) Attach additional pages as needed.
ADDITIONAL INFORMATION
EMPLOYMENT HISTORY EQUAL OPPORTUNITY EMPLOYER
Beginning with your present or most recent job, thoroughly describe your work experience. List each job separately, including paid, unpaid, and/or military experience. Resumes are not accepted in lieu of completing any section. 1.Employer Address From (Month) (Year)
Your Title
Supervisor’s Name and Telephone Number
Duties (Be specific)
To (Month) (Year)
Total Time (Month) (Year)
Hours/week: Paid Unpaid Start Salary: $ (Monthly) Last Salary: $ May we Reason for leaving / Desiring to leave contact? Yes No Explain any gap in employment: 2. Employer Address
(Monthly)
From (Month) (Year)
Your Title
Supervisor’s Name and Telephone Number
Duties (Be specific)
To (Month) (Year)
Total Time (Month) (Year)
Hours/week: Paid Unpaid Start Salary: $ (Monthly) Last Salary: $ May we Reason for leaving / Desiring to leave contact? Yes No Explain any gap in employment: 3. Employer Address
(Monthly)
From (Month) (Year)
Your Title Duties (Be specific)
Supervisor’s Name and Telephone Number
To (Month) (Year)
Total Time (Month) (Year)
Hours/week: EQUAL OPPORTUNITY EMPLOYER
Paid Start Salary:
Unpaid $ (Monthly)
Last Salary: May we Reason for leaving / Desiring to leave contact? Yes No Explain any gap in employment:
$ (Monthly)
BUSINESS / PROFESSIONAL REFERENCES Name
Relationship Address
Phone
Employment is subject to passing a criminal history background check. My written or electronic signature below certifies that: 1) All answers and statements on this application are true and complete to the best of my knowledge. I understand that should an investigation disclose untruthful or misleading answers or omissions, my application may be rejected, my name removed from consideration or my employment with Polk SWCD terminated. 2) I hereby authorize Polk SWCD to obtain information from my former employers and others in determining my qualifications and suitability to fill the position I seek, including information of a confidential or privileged nature. I release Polk SWCD from liability that may result from obtaining the information requested for the purpose specified herein. This release will expire one year after the date it is signed. 3) I understand that not every candidate who applied for this position will be offered an interview. 4) I understand and agree the Polk SWCD will obtain a criminal history background and a driving record check. 5) I understand that Supplemental Questions are required and if I do not provide complete written answers to those questions, my application will be automatically rejected. 6) I understand if my application is incomplete, it will be rejected and I will be removed from consideration. NOTE: Application must contain a written signature if dropped off at office, or submitted via mail. Application must contain an electronic signature if submitted via e-mail. (If submitted with an electronic signature, you will be required to sign you application at the interview, if you are EQUAL OPPORTUNITY EMPLOYER
selected to interview). Applications will not be processed without a signature (either written of electronic).
Written Signature
Electronic Signature (Type name. Electronic signature required only when submitting application via e-mail.)
DATE:
DATE:
Send Applications to:
Polk SWCD, Attn: Manager 580 Main Street, Suite A Dallas, Oregon 97338
Questions? Phone (503) 623-9680, EXT 110
Or email Applications to: polkswcdhiring@gmail.com
EQUAL OPPORTUNITY EMPLOYER