Application for Employment

Instructions to Applicant Complete this application in full by printing in ink or typing. All blanks must be completed, even if you have attached a resume. When you have completed the application, please submit it to the agency by one of the following methods: 503-261-0988 jobs@albertinakerr.org (Scan the completed application to a .pdf file, or save the completed Microsoft Word form, and attach the file to your email.) US Mail: Albertina Kerr Centers, Attn. Human Resources, 722 NE 162nd Ave., Portland, OR 97230 Albertina Kerr Centers is an equal opportunity employer. We provide reasonable accommodations in the pre-employment process to applicants with disabilities. For more information about our equal employment opportunity policy or to request reasonable accommodations, contact Human Resources at 503-239-8101. Employment Sought and Availability Position Desired Work Preference Full time Part Time On-Call Temporary/Seasonal Work Availability Sunday Monday Tuesda Wednes Thursd Friday Saturda y day ay y Availabl e From To Schedules are set according to agency need and may vary from time to time. Date available to start work Wage/Salary Expected $ per How did you learn of this opening? Please list the specific person, publication, or website. Newspaper Which paper? Online Posting Which site? Unemployment Office/WorkSource Kerr Employee Whom? Other Source Please specify Personal Information Last Name First Name Middle Name Mailing Address City State ZIP We require all employees be legally authorized to Home Phone Message Phone Email Address Are you at least 18 years of age? Fax: Email:

work in the United States. Upon hire, can you provide proof of your eligibility to work in the US? Yes No Kerr positions require a Criminal History Check. Have you ever been convicted of a felony or misdemeanor? (Conviction is not necessarily a bar to employment.) Yes No If yes, please fully explain in the continuation area on page four.
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Yes No If not, what is your date of birth? Have you ever worked or volunteered for Kerr? Yes No If yes, when and where?

Rev. March, 2009

Employment and Work Experiences Starting with your current or most recent employer, list all work experiences for the last seven years. If you have not worked in the last seven years, list your most recent experiences regardless of how long ago they were. Use the continuation space on page four or attach a separate page as necessary. Include all jobs, full-time and part-time volunteer work and internships, and activeduty military or national service experiences. Explain any periods of unemployment longer than 90 days. Use the continuation space on page four or attach a separate page as necessary. You must complete this section in full even if your resume is attached. Applications marked See resume will be rejected. Name and address of employer Telephone Job Title Supervisors Name and Title Primary Duties Dates of Employment (Month and Year) From To Reason for leaving or considering a change Starting Pay$ per Ending Pay $ per May we contact this employer for a reference? Yes No Name and address of employer Telephone Job Title Primary Duties Reason for leaving Name and address of employer Job Title Primary Duties Reason for leaving Name and address of employer Job Title Primary Duties Reason for leaving or considering a change Supervisors Name and Title Dates of Employment (Month and Year) From To Starting Pay$ per Ending Pay $ per Telephone Supervisors Name and Title Dates of Employment (Month and Year) From To Starting Pay$ per Ending Pay $ per Telephone Supervisors Name and Title Dates of Employment (Month and Year) From To Starting Pay$ per Ending Pay $ per

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Education High School or GED Program Location College Location College Location Technical or Career School Location Professional License, Registration, or Certification

Did you graduate/complete? Yes No Did you graduate? Yes Degree and Major Did you graduate? Yes Degree and Major Major course of study

No No

Professional Memberships and Affiliations (Omit organizations that reveal race, ethnicity, or religious or political preferences)

Issuing State/Body and Number Expiration Date

Special Skills and Qualifications Summarize any other job-related skills and qualifications you believe are relevant to the position

Do you have a valid drivers license? Yes No Please list any traffic accidents and citations in the past two years (excluding parking violations). Use the continuation space on page four or attach a separate page as necessary. Violation Date Resolution (not/at fault, convicted, etc.) References We will not contact your present employer without first discussing it with you. We will contact previous supervisors listed in the Employment section. Please list below any additional contact information to help us reach your previous supervisors or additional jobrelated references who can attest to your qualifications. Do not include relatives or personal references, please. Name Title and Phone Number Years How Acquainted Occupation Acquainted


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Continuation Please use this area to explain any criminal history, to continue listing your employment and work experiences, to explain any periods of extended unemployment, or to continue listing your driving history. Attach additional pages, if necessary, to fully explain these items.

Authorization, Agreement, and Acknowledgement by Applicant I certify that the facts and information set forth in this application and in any resume or supplemental materials are true and correct. I understand that any falsification, misrepresentation, or omission of fact in this application or in any resume or supplemental materials will cause the denial or termination of employment, regardless of how or when discovered. I authorize the investigation of all matters which Albertina Kerr Centers (Kerr) deems relevant to my qualification for employment, including my work history and all statements in this application or any accompanying materials. I authorize any parties contacted to cooperate in this investigation and I release them from any liability that may result from the investigation. All offers of employment with Kerr are contingent upon completion of a preemployment drug screen within 24 hours of an offer of employment, a Criminal History Check, a substantiated abuse allegations check, and verification of previous employment. My failure to participate in any of these activities as directed or to meet Kerrs requirements regarding same will result in revocation of my offer or termination of my employment. I understand that employment with Kerr is conditioned upon my lawful eligibility for employment in the United States. I will be required to provide proof of my identity and employment eligibility pursuant to the Immigration Reform and Control Act of 1986 as amended, and my failure to do so will result in my termination. I understand and agree that if I am offered and accept a position, such employment is at-will, and either I or Kerr may terminate employment, with or without cause, at any time. I understand that no employee or representative of Kerr other than the President/CEO (or his or her authorized representative) has any authority to enter into any employment agreement for any specified period of time or contrary to the terms stated in this application, and that any such agreement by the President/CEO (or his or her authorized representative) must be in writing to be valid. I agree to conform to all existing and future Kerr rules, regulations, and policies, and I understand that Kerr has the right to change wages, hours, and working conditions at its discretion.

I have read and understand the above statements and the other information provided on this application. _________________________________________________________ ______________________ Signature of Applicant Date Electronic signatures are not accepted. If you are submitting this application electronically and you are offered employment, you will be required to physically sign the application prior to beginning work.
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