EMPLOYMENT APPLICATION

¿ Unsigned or incomplete applications will not be processed. ¿

You may attach a resume and supporting documents.

EDUCATION List any education, training and/or specialized experience (such as trade, vocational or technical school) you feel would help you perform the work and responsibilities of the position for which you are applying.

Name of the Institution / Location
(city & state) / Course of Study / Years Completed / Diploma
or Degree Yes / No
or # of credits
High School
or Equivalent
Undergraduate College or University
Graduate School
Trade or Vocational School
Trade or Vocational School
Education in the Military
Describe any other specialized training, education, apprenticeship, license, certifications, or extra-curricular activities you believe are relevant or would help you perform the duties of the position you are applying for. Indicate where you acquired them or the issuing authority for licenses.

Military Work History

Have you ever served in the U.S. Armed Forces, National Guard or Military Reserves? [ ] Yes [ ] No If yes,

Branch & Division: ______Years of Service: ______

Job Class or Specialty: ______


Employment History

Starting with your present or most recent employer please list your experience. If more space is needed, continue in a separate sheet. You may attach a resume, but please note this portion of the application must be completed in full.

Last or present company Type of Business Title of position held Current Salary
Street address Phone # Position was:
 Temporary  Part-Time  Full-time
______
City State Zip Code Brief description of job duties
______
Supervisor’s Name & Title
______
Dates Employed (mo./yr.) From: To: ______
Reason for leaving or seeking other employment
______
May we contact your current employer? [ ] Yes [ ] No
______

3
Company Type of Business Title of position held Last Salary
Street address Phone # Position was:
 Temporary  Part-Time  Full-time
______
City State Zip Code Brief description of job duties
______
Supervisor’s Name & Title
______
Dates Employed (mo./yr.) From: To: ______
Reason for leaving or seeking other employment
______

Company Type of Business Title of position held Last Salary
Street address Phone # Position was:
 Temporary  Part-Time  Full-time
______
City State Zip Code Brief description of job duties
______
Supervisor’s Name & Title
______
Dates Employed (mo./yr.) From: To: ______
Reason for leaving or seeking other employment
______

Company Type of Business Title of position held Last Salary
Street address Phone # Position was:
 Temporary  Part-Time  Full-time
______
City State Zip Code Brief description of job duties
______
Supervisor’s Name & Title
______
Dates Employed (mo./yr.) From: To: ______
Reason for leaving or seeking other employment

Criminal Record: (A criminal record is not an automatic bar to employment. Do not list any arrest, charge or detention that did not result in conviction or any arrest, detention or conviction that has been judicially expunged, sealed, impounded or eradicated.) Have you been CONVICTED, pled GUILTY or NO CONTEST, or FORFEITED BOND OR BAIL for any crime in the last 10 years? [ ] Yes [ ] No If yes, please explain:

______

List any other skill or qualification that you believe is relevant to the position you are applying for.

Voluntary Self-Identification Form

The Agency on Aging and Disabilities of Southwest Washington is an Equal Opportunity Employer.
Applicants for employment are invited to participate in the Affirmative Action Program by reporting their status as handicapped, disabled veteran, veteran of the Vietnam era or other minority. In extending this invitation you are also advised that: (a) applicants are under no obligation to respond, but may do so in the future if they choose; (b) responses will remain confidential within the Human Resources Department; and (c) responses will be used only for the necessary information to include in our Affirmative Action Program. We are an agency that values diversity. We actively encourage women and minorities to apply. Refusal to provide this information will have no bearing on your application and will not subject you to any adverse treatment.
Please complete the information below. Thank you for your cooperation.
Position Applied For: / Date:
Race or Ethnic Identity / Gender / Veteran Status
  Hispanic or Latino
  White (not Hispanic or Latino)
  Black or African American (not Hispanic or Latino)
  Native Hawaiian or Pacific Islander (not Hispanic or Latino)
  Asian (not Hispanic or Latino)
  American Indian or Alaskan Native (not Hispanic or Latino)
  Two or more races (not Hispanic or Latino) /   Male
  Female /   Vietnam Era Veteran
  Special Disabled Veteran
  Other Protected Veteran
  Recently Separated Veteran
  Armed Forces Service Medal Veteran
Other:
  Individual with Disabilities
How did you hear of our opening? Advertisement (specify): ______
Our website: Other website: Employee referral: Other (specify): ______
I do not wish to Self-Identify:

Voluntary Self-Identification of Disability

Form CC-305

OMB Control Number 1250-0005
Expires 1/31/2017

Why are you being asked to complete this form?

Because we do business with the government, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities.[i] To help us measure how well we are doing, we are asking you to tell us if you have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will choose to fill it out. If you are applying for a job, any answer you give will be kept private and will not be used against you in any way.

If you already work for us, your answer will not be used against you in any way. Because a person may become disabled at any time, we are required to ask all of our employees to update their information every five years. You may voluntarily self-identify as having a disability on this form without fear of any punishment because you did not identify as having a disability earlier.

How do I know if I have a disability?

You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition.

Disabilities include, but are not limited to:

·  Blindness / ·  Autism / ·  Bipolar disorder / ·  Post-traumatic stress disorder (PTSD)
·  Deafness / ·  Cerebral palsy / ·  Major depression / ·  Obsessive compulsive disorder
·  Cancer / ·  HIV/AIDS / ·  Multiple sclerosis (MS) / ·  Impairments requiring the use of a wheelchair
·  Diabetes
·  Epilepsy / ·  Schizophrenia
·  Muscular dystrophy / ·  Missing limbs or partially missing limbs / ·  Intellectual disability (previously called mental retardation)

Please check one of the boxes below:

☐ / YES, I HAVE A DISABILITY (or previously had a disability)
☐ / NO, I DON’T HAVE A DISABILITY
☐ / I DON’T WISH TO ANSWER

______

Your Name Today’s Date

Voluntary Self-Identification of Disability

Form CC-305

OMB Control Number 1250-0005
Expires 1/31/2017

Page 2 of 2

Reasonable Accommodation Notice

Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of reasonable accommodation include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment.

______

Section 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal employment obligations of Federal contractors, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp.

PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. This survey should take about 5 minutes to complete.

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