2800 N. Vancouver , Suite 100
Portland , Oregon 97227
Phone: (503) 413-1850 FAX: (503) 413-1851
E-mail: johnb@aahc-portland.org
Web site: www.aahc-portland.org
EMPLOYMENT APPLICATION
TYPE or PRINT
Job Title: __________________________________________________________________________
Social Security Number: ________ _____ ___________
Last Name: ___________________________________________________________________
First Name __________________________________________ Middle Initial _________
Address: _________________________________________________________________________
City _____________________________ State __________ Zip ____________________
Home Phone (_______)_____________________ e-mail _________________________
Work Phone (_______)_____________________ Extension ______________
Message Phone (_______)_____________________
EDUCATION AND TRAINING
List below the Education and Training you have had that would help you meet the requirements of this position.
Name and Location of High School, Technical Training, College, University, or Sponsoring Organization |
Course or Program of Study |
No. of Credits |
Degree or Certificate |
1. |
|
|
|
2. |
|
|
|
3. |
|
|
|
4. |
|
|
|
5. |
|
|
|
Current License or Certification for this position: ______________________________________________
EMPLOYMENT HISTORY
INSTRUCTIONS : Beginning with your present or most recent job, describe your work experience (paid or volunteer), which is relevant to the position for which you are applying. The information provided on this application form (and any additional employment history which may be attached) will be used to determine if you meet the minimum qualifications for the position. Resumes may be submitted but will not be considered as a substitute for this form.
Job Title ___________________________________ Employer: __________________________________
Supervisor: _________________________________ Address: ___________________________________
Telephone __________________________________ City / State/ Zip: _____________________________
Starting Date: _________Ending Date: ___________ Starting Salary: _________Ending Salary: ________
Average Number of hours worked per week: _______ May we contact this employer? Yes: ____No: ____
Duties and Responsibilities: _______________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Reason for Leaving: _____________________________________________________________________
Job Title: ___________________________________ Employer: _________________________________
Supervisor: _________________________________ Address: ___________________________________
Telephone: _________________________________ City / State/ Zip: ______________________________
Starting Date: __________Ending Date __________ Starting Salary __________Ending Salary: ________
Average Number of hours worked per week: ______ May we contact this employer? Yes: ____ No: _____
Duties and Responsibilities: _______________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Reason for Leaving: _____________________________________________________________________
Job Title: ___________________________________ Employer: _________________________________
Supervisor: _________________________________ Address: ___________________________________
Telephone: _________________________________ City / State/ Zip: _____________________________
Starting Date: __________Ending Date: _________ Starting Salary: __________Ending Salary: ________
Duties and Responsibilities: _______________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Reason for Leaving: _____________________________________________________________________
My signature affirms that I release from liability any employer, person, or employee supplying references information regarding me, or my previous employment. I also release AAHC from all liability, which may result from making any investigation information provided in the application materials. All information on this application is true to the best of my knowledge. I understand that falsification or misrepresentation may result in disqualification or dismissal.
Signature: ___________________________________________ Date: _____________________________
PERSONAL REFFERENCES
Please list the names and contact information for three people you have known for at least two years (no family members please.). Please note that we may contact one or all of these individuals.
Name |
Occupation |
Years Known |
Phone Number |
|
|
|
|
|
|
|
|
|
|
|
|
PLEASE ANSWER THE FOLLOWING QUESTIONS
When are you available to begin work? __________________________________________________
Do you have reliable transportation (car, bus, carpool, etc.)? ____________________________________
Are you available to work (circle one) Full Time Part Time
If part time, please indicate the hours/days you are available ____________________________________
Do you have a significant other, relative or friend who currently (or previously) works for the AAHC? If yes, please state name(s): ______________________________________________________________________________________
______________________________________________________________________________________
Have you been convicted of a felony within the last ten years? If yes, please provide the following information: date, jurisdiction, nature of offense, sentence, dates of incarceration if any, and any other information that will help us evaluate this event. Please note that a conviction is not an automatic disqualification from employment. ______________________________________________________________________________________
______________________________________________________________________________________
_____________________________________________________________________________________
______________________________________________________________________________________
Do you require any specialized needs or equipment to perform the duties outlined in the job description? If yes please explain? _____________________________________________________________________
______________________________________________________________________________________
TECHNICAL SKILLS
Please indicate your computer proficiency by circling your skill level.
Microsoft 2000
Word Beginner Intermediate Advanced
Excel Beginner Intermediate Advanced
Publisher Beginner Intermediate Advanced
PowerPoint Beginner Intermediate Advanced
Access Beginner Intermediate Advanced
Typing ______WPM
This EEO data is used for compliance and monitoring purposes only in order to further the objectives of Equal Employment Opportunity. Providing this data is optional.
Social Security Number: _________________ _____________ ________________________
Date of Birth: Month: ___________________ Day____________ Year: _________________
Sex: Male: __________ Female: ____________
Ethnic Category: (check one): Black: ___ Hispanic: ___ White: ___ Native American: ___ Asian: ___
Description of Ethnic Categories :
BLACK (not of Hispanic origin)—All persons having origins in any of the Black racial groups of Africa .
HISPANIC—All persons of Mexican, Puerto Rican, Central or South America , or other Spanish culture or origin, regardless of race.
WHITE: (Not of Hispanic origin)—All persons having origins in any of the original peoples of Europe, North Africa, or the Middle East .
NATIVE AMERICAN: (American Indian or Alaskan Native)—All persons having origins in any of the original peoples of North America, and who maintain cultural identification through tribal affiliation or community reception.
AISIAN: (Asian or Pacific Islander)—All persons having origins in any of the original peoples of the Far East, Southeast Asia, the Indian Subcontinent or the Pacific Islands. This area includes: China , Japan , Korea , the Philippine Islands, and Samoa .
We are interested in how you found out about this employment opportunity. Pleas indicate below the resource you used. This information is not part of the application evaluation procedure and will only help us plan future recruitments.
• Walked into the Office
• Direct Mailing
• Cable TV
• Worldwide Website ( http://www.aahc-portland.org )
• The Oregonian
• The Scanner
• Other newspaper or publication ____________________________________(please indicate)
• Referred by AAHC Employee
• Other: _____________________________________________________________
2800 N. Vancouver , Suite 100
Portland , Oregon 97227
Phone: (503) 413-1850 FAX: (503) 413-1851
E-mail: johnb@aahc-portland.org
Web site: www.aahc-portland.org