Human Resources Veterans Affairs

CITY OF ROSEBURG

EMPLOYMENT APPLICATION

DIRECTIONS: Please print or type. Answer all questions. If the question does not apply to you or the position you are applying for, mark it “N/A”. Resumes are accepted in addition to application. Last First

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2. Name: Position Applying For: Date: Email Address: Cell Phone Number:

1.

CITY AND STATE

List other schooling including college, technical school, correspondence courses and other relevant experience.

7. EDUCATION RECORD: If now in school, include present term.

Middle

Is any additional information relative to change of name, assumed name or nickname necessary to enable a check on your work or education history? Yes No Explain 3. Physical Address: Street City State Zip Code

Mailing Address: Phone Number: 4. Are you eligible to work in the United States? Yes No 5. Employees of the City of Roseburg must be at least 18 years of age. Are you able to meet this requirement? Yes No

6. List any relatives currently employed by the City of Roseburg: NAME OF SCHOOL

What is the highest grade completed from 1 to 12 .

SCHOOL MAJOR SUBJECT UNITS COMPLETED DEGREE

8. EMPLOYMENT HISTORY: Beginning with your present or most recent job, describe your work history and experiences related to the position for which you are applying. INCLUDE ALL MILITARY, NON-PAID OR VOLUNTEER WORK RELATED TO THE POSITION. If additional space is needed to complete the question, attach a separate sheet of paper. to

Present or Last Employer: Phone: Address: Supervisor’s Name: Your Job Title: Hours Per Week: Employment Dates: From Reason for Leaving: May We Contact Your Employer? Yes No If no, why? Reason for Leaving:

Employment Dates: From to

Hours Per Week:

Employer: Phone: Address: Supervisor’s Name: Your Job Title: Reason for Leaving:

Employment Dates: From to

Hours Per Week:

Employer: Phone: Address: Supervisor’s Name: Your Job Title: Reason for Leaving:

Employment Dates: From to

Hours Per Week:

Employer: Phone: Address: Supervisor’s Name: Your Job Title: 9. Please explain any interruptions in your employment record as described in Question 9. 10. List any special training, licenses, certificates, machine skills, office equipment or other skills you may have that are pertinent to the position for which you are applying. All of the information included in this application or supplied by me during the application process is true and complete. I understand that any false or misleading statement or omission of fact in this application or during the application process will disqualify me from further consideration for employment or will result in termination of my employment.

If I am hired, I agree to conform to all rules and regulations of the City. I understand that any offer of employment will not be enforceable unless it is in writing. If hired, I am able to present documents proving my identity and eligibility to work as required by federal law.

I understand that, as part of the City’s employment procedures, I may be required to undergo testing carried out by a laboratory designated by the City. I consent to undergo any required drug testing. Finally, I understand that any offer of employment I might receive from the City may be made contingent upon, among other things, satisfactory completion of a post-offer medical examination and a determination by the City that I am capable of performing the essential functions of the position that has been offered, with or without reasonable accommodation.

I authorize investigation of all statements contained in this application and any other information about me relevant to my qualifications for employment. I hereby release and agree to indemnify and defend the City of Roseburg, its employees, officers, agents and representatives, from all liability, claims or damage resulting from this investigation.

SIGNATURE OF APPLICANT DATE

APPLICANT: The following information is requested purely for statistical purposes. Responding to these questions is voluntary. Whether or not you choose to respond to the questions will not affect the status of your application.

Gender: Male Female Non-binary

Race/Ethnic Group: Hispanic Asian Black or African American Native Hawaiian or other Pacific Islander White Check if any of the following are applicable:

Veteran __ __ Disabled Veteran __ __ Handicapped Individual Eligible for Veteran’s Preference (Complete Veteran's Preference Form) Indeed LinkedIn

Where did you first learn about this employment opportunity? City Website Facebook

Other (describe):

American Indian/Alaskan Native Two or more races CITY OF ROSEBURG

Veteran’s Preference Form

Under Oregon law, veterans who meet minimum qualifications for a position may be eligible for employment preference. If you think you may qualify, please read the following checklist carefully. Check the box for each item that is appropriate. If you need further explanation or have special circumstances, please call Human Resources at 541-***-****.

This completed form and required documentation must be submitted to the City of Roseburg Human Resources Department at the time you submit your employment application. A. QUALIFIED VETERAN QUESTIONS: You may claim veteran’s preference if you check at least one box in each of the four sections below and provide proof of eligibility by submitting a copy of your DD-214 and 215.

ORS 408.225(d)

I served on active duty with the Armed Forces of the United States for a period of more than 178 consecutive days and was discharged or released under honorable conditions; or I served on active duty with the Armed Forces of the United States for 178 days or less and was discharged or released from active duty under honorable conditions because of a service-connected disability; or

I served on active duty with the Armed Forced of the United States for at least one day in a combat zone and was discharged or released from active duty under honorable conditions; or I received a combat or campaign ribbon for service in the Armed Forces of the United States.

“Active duty” does not include attendance at a school under military orders, except schooling incident to an active enlistment or a regular tour of duty, or normal military training as a reserve officer or member of an organized reserve or a National Guard unit.

B. QUALIFIED DISABLED VETERAN QUESTIONS: You may claim additional employment preference if you can check at least one box in each of the three sections below and provide proof of eligibility by submitting both of the documents listed below:

1. A copy of your DD 214 and 215, Certificate of Release or Discharge, Copy 4, and 2. A public employment preference letter from the United States Department of Veterans’ Affairs. To order the letter, call 1-800-***-**** and request a public employment preference letter. ORS 408.225(b)

I am entitled to disability compensation under laws administered by the United States Department of Veterans Affairs; or

I was discharged or released from active duty for a disability incurred or aggravated in the line of duty; or I was awarded the Purple Heart for wounds received in combat. I hereby claim veteran’s preference points and certify that the above information is true and correct. I understand any false statements may be cause for my disqualification or dismissal, regardless of when discovered.

Print Name

Signature of Applicant

Date

ORS 408.225.230: Preference will not be awarded without the appropriate documentation. You must submit your DD-214 and 215 in all cases. If you are claiming disabled veteran points, you must also submit the public employment preference letter from the Department of Veterans Affairs. You will not receive preference without these accompanying documents.

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