Mid-Willamette Valley Community Action Agency

2475 Center Street

Salem, OR 97301

(503) 585-6232

Employment Application

Each position you apply for must have a separate application packet, which includes all requested application materials. Applications received incomplete, missing the requested materials, or after 5:00 pm on the day of closing will not be considered for a position. Faxed applications will not be accepted.

You may email your application, with all requested documents attached, to . Signatures for emailed applications will be obtained, in person, for those candidates selected for interview.

Please be aware that all persons offered a position with Mid-Willamette Valley Community Action Agencymay be required to complete some or all of the following prior to being able to begin work:

Criminal History check
Central Background Registry with Child Care Division
Proof of eligibility to work in the United States
TB Test
Physical Exam
Drug Screen
Class ‘B’ Commercial Driver’s License or Permit
School Bus driver license endorsement (‘S’ Endorsement)
Passenger driver license endorsement (‘P’ Endorsement)
Passing score on Air Brakes knowledge test
Oregon School Bus Driver’s Certificate
Proof of current automobile insurance
Department of Motor Vehicles Check
Food Handler’s Card
CPR / First Aid Certification

Revised 8/5/2011

Mid-Willamette Valley Community Action Agency

2475 Center Street NE

Salem, Oregon97301

(503) 585-6232

APPLICATION FOR EMPLOYMENT

Please type or print in ink. Please complete all sections of application, and attach any additional materials as requested in the job announcement. Incomplete, illegible, or unsigned applications* will be eliminated from consideration. *Signatures for emailed applications will be obtained, in person, for those candidates selected for interview.
Position Applying for:
Name:
Address / City / State / Zip Code
Mailing Address (if different) / City / State / Zip Code
Home Phone: / Cell Phone: / Message Phone:

How did you hear about this position?

Career Builder / Employment Department / In-house Announcement
Job Dango / Chemeketa / Employee
Salem Job Finder / Itemizer Observer / Agency website
Craigslist / Statesman Journal Other:

Have you been employed or attended school using any other name? Yes No

If yes, under what name:

Have you ever worked for Community Action Agency before? Yes No

If yes, dates you were employed:

Are you legally eligible for employment in the United States? Yes No

Are you 18 years of age or older? Yes No

Have you ever been convicted, pled guilty or no contest to a crime? Yes No

If yes, list offense, date, location, and penalty:

A conviction is not an automatic bar to employment

Have you ever been convicted, pled guilty or no contest to a

major traffic violation? Yes No

If yes, list offense, date, location, and penalty:

Qualifications

Do you have a High School Diploma or GED Certificate? Yes No

Education

Name of School / List Degree Achieved or Credits Completed
College:
List Major
College:
List Major
Other:
Course of Study

Specialized Skills and Knowledge

List skills or knowledge that show your ability to perform the job for which you are applying,

such as computer languages or software programs, etc. Attach additional pages as needed.

What is your typing speed? wpm

Do you speak another language in addition to English? Yes No

If yes, what other language(s) do you speak:

Do you have a valid Oregon Driver’s License? Yes No

Do you have a Class ‘B’ Commercial Driver’s License or Permit? Yes No

If yes, list endorsements currently held:

Do you have a current Oregon School Bus Driver’s Certificate? Yes No

Are you currently registered in the Central Background Registry w/CCD? Yes No

Do you have a Food Handler’s Card or Food Manager’s Certificate? Yes No

Are you now, or have you ever been a Head Start Parent? Yes No

Personal References

List three references WHO ARE NOT LISTED AS A SUPERVISOR IN THE EMPLOYMENT HISTORY SECTION, and who are not related to you by blood or marriage. List those who can provide information regarding your work history or skills.

Name / Relationship / Telephone (with area code) / E-mail Address (optional)
1.
2.
3.

Employment History

The information you provide in the “Employment History” section will be used to evaluate whether you meet the minimum qualifications listed in the job announcement. We will not consider experience that is not listed in this section. List all relevant experience in this section.Start with your current or most recent job, list all your jobs (including volunteer work, part-time, or self-employment) for the last ten years. You may wish to include qualifying experience gained more than 10 years ago, if it helps you qualify for the job. You may attach additional pages if necessary.

**A resume will not substitute for completing this section of the application.**

From (Month/Year) / To (Month/Year) / Your Job Title / Average Hours
Per Week: / Ending Salary
Name of Employer / Employer Address, City, State & Zip
Supervisor’s Name / Phone Number (with area code)
Duties:
Reason for Leaving: / May we contact?
From (Month/Year) / To (Month/Year) / Your Job Title / Average Hours
Per Week: / Ending Salary
Name of Employer / Employer Address, City, State & Zip
Supervisor’s Name / Phone Number (with area code)
Duties:
Reason for Leaving: / May we contact?

Employment History Continued

You may attach additional pages if necessary.

Explain how you meet the minimum qualifications as stated in the job announcement.

Be sure any experience listed in this section is also listed in the Employment History section.

APPLICANT AUTHORIZATION FOR RELEASE OF INFORMATION

I hereby authorize my past employers to release information to Mid-Willamette Valley Community Action Agency regarding my employment. This release of information covers my employment record in general, including information pertaining to the following questions:

Dates of employment;
Positions(s) held;
The quality and quantity of my work;
My attendance habits (EXCLUDING worker’s compensation, pregnancy, disability and protected absences);
My relationship with co-workers and supervisors;
My attitude toward work (cooperative? positive? etc.);
Reason for leaving and eligibility for rehire;
Strengths and weaknesses:
Whether I have had outbursts of temper, threatened, provoked fights with or assaulted others, engaged in hostile or violent behavior, have a criminal record or any traits that would present security or safety issues for others;
Other relevant information regarding my performance, skills, ability, and suitability for employment sought, etc.

I agree that all former employers who provide such information are indemnified and released from liability arising from such disclosures. I also understand that if I do not sign this Authorization for Release of Information, my application will be rejected.

Print Name

SignatureDate

APPLICATION STATEMENT

I certify that all information I have provided in order to apply for and secure work with the Mid-Willamette Valley Community Action Agency (Community Action) is true, complete, and correct.

I understand that any information provided by me that is found to be false, incomplete, or misrepresented in any respect, will be sufficient cause to 1) cancel further consideration of this application, or 2) immediately discharge me from Community Action, whenever it is discovered.

I expressly authorize, without reservation, Community Action, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities, and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume, or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees, or representatives, for seeking, gathering and using such information in the employment process and all other persons, corporations or organizations for furnishing such information about me.

I understand that Community Action does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant from consideration for employment on a basis prohibited by applicable local, state, or federal law.

I understand that this application pertains only to the current, open position. If I wish to be considered for another position, it will be necessary to reapply and submit a new application.

I understand that for some positions I must be enrolled in the Criminal History Registry of the Child Care Division of the Employment Department and/or submit to a Criminal Background check. I understand that some positions may require that applicants submit to a post-offer, pre-employment drug screen, physical exam, Tuberculosis Test, and/or pass a DMV records check. For Head Start positions, I understand that Policy Council approval is required before I may be hired.

If I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of Community Action is authorized to make any assurances to the contrary and that no implied or written agreements, contrary to the foregoing express language, are valid unless they are in writing and signed by the Executive Director of the Mid-Willamette Valley Community Action Agency.

I also understand that if I am hired, I will be required to provide proof of identity and legal authority to work in the United States and that federal immigration laws require me to complete an I-9 Form in this regard.

DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT

I certify that I have read, fully understand, and accept all terms of the above Applicant Statement.

Signature of Applicant Date

Please keep a copy of your application. Copies will not be provided.