701 West Eighth Street
P.O. Box 180, Vancouver, WA 98666
(360) 694-3391
Name
of agency or person who referred you:_______________________ Date:___________________________
NAME (last, first, middle): _____________________________________________________________________
ADDRESS: Number, Street______________________________City_____________State________Zip________
Telephone: ___________________________________ Date of Birth if you are under 18:___________________
Position(s) applied for: _______________________________________ Earnings expected: ________________
Date available for work: ___________________ Message name and phone number: ______________________
Do you want: Full-time _____ Part-time _____ Weekends _____ Evenings _____ Temporary _____
Days/Hours not available for work: ______________________________________________________________
Have you applied or worked here before? If yes, when? __________________________
EDUCATION
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| Describe specialized skills, training, or apprenticeships |
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Do you plan to continue your education? Yes __ No __ If yes, what course of study and when? _________________________________________________________________________________________
Computer skills & software: ____________________________________________________________________
Number of years experience ______________
Other skills/Equipment ______________________________________________________________________
Us Military, if any: Yes ___ No ___
Have you been convicted of a crime with in the last seven years? Yes ___ No ___ If yes, please explain:
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WORK HISTORY Include part-time jobs, summer jobs, businesses of your own, volunteer work. Incomplete applications will not be considered |
Note: | If additional space is needed to list your jobs, please print a second application at the desk, or add an addtional sheet. |
Employer: __________________________________________ Address: _____________________ Telephone: ____________ Job title: _______________ Supervisor: ___________________ Reason for leaving: _______________________________________ _______________________________________________________ |
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Employer: __________________________________________ Address: _____________________ Telephone: ____________ Job title: _______________ Supervisor: ___________________ Reason for leaving: _______________________________________ _______________________________________________________ |
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Employer: __________________________________________ Address: _____________________ Telephone: ____________ Job title: _______________ Supervisor: ___________________ Reason for leaving: _______________________________________ _______________________________________________________ |
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Employer: __________________________________________ Address: _____________________ Telephone: ____________ Job title: _______________ Supervisor: ___________________ Reason for leaving: _______________________________________ _______________________________________________________ |
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Employer: __________________________________________ Address: _____________________ Telephone: ____________ Job title: _______________ Supervisor: ___________________ Reason for leaving: _______________________________________ _______________________________________________________ |
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Employer: __________________________________________ Address: _____________________ Telephone: ____________ Job title: _______________ Supervisor: ___________________ Reason for leaving: _______________________________________ _______________________________________________________ |
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Indicate by number of the above employers you do not wish us to contact: ___________________________
If you've worked under other names, please give name(s): _______________________________________
Please read carefully and sign.
I certify that
the information I provided on this application is true and correct. I
understand that falsification of any of the information asked on this
application will be grounds for my immediate termination from the Company.
I authorize my previous employers to release to The Columbian and all
information regarding my prior employment and release them from liability
for any such disclosures. I also understand that I will be subject to
reasonable suspicion drug or alcohol testing during my employment, if
hired; I agree to such testing and authorize the testing facility to release
the results to The Columbian. I also understand and agree that if I am
subsequently hired by The Columbian, my employment shall continue "at-will"
as long as is mutually agreeable to both The Columbian and me. I know
that this provision regarding the at-will nature of my employment cannot
be modified except in writing, signed by the Human Resources Manager.
Lastly, I understand that this paragraph sets forth the entire agreement
between The Columbian and me with regards to the at-will nature of my
employment.
Signature _____________________________________________
The Columbian is an equal Opportunity Employer. Federal and State laws prohibit discrimination in employment because of sex, age, race, color, religion, marital status, national origin, ancestry, or disability.