Employment Application Employment ApplicationPlease read before continuing Thank you for your interest in working for the Port of Siuslaw. The port makes decisions regarding employment without regard to race, color, sex, national origin, religion, marital status, sexual orientation, age, prior industrial injury, mental or physical disability, or any other protected classification unrelated to job performance, This application will be considered only for the specific job applied for; it will not be retained. Please fill out everything and if you need additional space there will be a text area at the bottom of the form to add additional information. Incomplete applications will not be considerd. The Electronic Signatures Act (Public Law No: 106-229) went into effect on October 1, 2000 and gives electronic contracts the same weight as those executed on paper. So when you hit the "Submit" button you just signed your application. Position applied for First Name * Middle Name Last Name * Street Address * Mailing Address (if different) Home Phone * Cell Phone Work Phone Email * Social Security Number * Driver's Licence Number & State * Are you over 18 years of age? *YesNo Do you have a high school diploma YesNo If so, name and location of school graduated or where the GED was obtained Please describe any additional education, training, or skills relevant to this position Have you been convicted of a felony on or after your 18th birthday? *YesNo If YES, please explain the circumstances of the conviction, including date, nature and place of offense and disposition. Convictions are not necessarily disqualifying. Next Page 1 / 2Employment HistoryCurrent Employer Address Supervisor Name and Phone Number Job Title From (month-Year) To (month-year) Total time worked (years & months) I worked (select) Full TimePart TimeTemporary Rate of Pay Per Hour or Salary? Specific Duties Performed Reason for Leaving May we contact this employer Select oneYesNo Employer 2 - If none skip this sectionPrevious Employer Address Supervisor Name and Phone Number Job Title From (month-Year) To (month-year) I worked (select) Full TimePart TimeTemporary Rate of Pay Per Hour or Salary? Specific Duties Performed Reason for Leaving May we contact this employer Select oneYesNo Employer 3 - If none skip this sectionPrevious Employer Address Supervisor Name and Phone Number Job Title From (month-Year) To (month-year) I worked (select) Full TimePart TimeTemporary Rate of Pay Per Hour or Salary? Specific Duties Performed Reason for Leaving May we contact this employer Select oneYesNo VerificationPlease enter any two digits *Example: 12This box is for spam protection - please leave it blank 2 / 2
