An Equal Opportunity Employer

Application for Employment

This is a preliminary application. Once submitted, you will receive a confirmation and a copy of your submission by e-mail, and your information will be evaluated by our Human Resources Department. We will contact you by telephone or e-mail. Please complete this form fully, honestly and accurately.

PERSONAL DATA

Application Date                       Date you are available to begin work

First Name       Middle Name       Last Name

Address

City    State    Zip Code

Telephone: Residence   Message   E-mail

Are you at least 18 years of age?  Yes   No

Are you legally eligible to work in the United States of America?  Yes   No

Please list any relevant military experience

JOB INTEREST

For what job are you applying? (Please be specific)

Who referred you to Seneca, or what prompted your application?

I am willing to work (Check all that apply):  Days   Swing  Graveyard

Are you willing to work occasional overtime? Yes  No

Are you willing to work occasional weekends? Yes No

Have you ever worked for Seneca before? Yes No

If yes, please give dates of employment, location and job title

Have you ever applied for work at Seneca before?  Yes No

If yes, please give date and job for which you applied

EDUCATION AND TRAINING (Please complete for each school attended.)

	School Name/Location	Major Course of Study	Number of years attended write “YES” if graduated	If graduated, give degree/certificate and date (except high school)
HIGH SCHOOL
GED (if applicable)
TRADE SCHOOL
COLLEGE
OTHER

Work history

(Please list your jobs in the exact order of occurrence. Begin with your current job or most recent job, if unemployed.)

Name of Employer Type of Industry

Employer's Location Phone

Dates of Employment (from Month/Year) (to Month/Year)

Your Job Title/Responsibility

Your Supervisor's Name & Title Your Last Rate of Pay

Your Reason For Leaving (please be specific)

Name of Employer Type of Industry

Employer's Location Phone

Dates of Employment (from Month/Year) (to Month/Year)

Your Job Title/Responsibility

Your Supervisor's Name & Title Your Last Rate of Pay

Your Reason For Leaving (please be specific)

Name of Employer Type of Industry

Employer's Location Phone

Dates of Employment (from Month/Year) (to Month/Year)

Your Job Title/Responsibility

Your Supervisor's Name & Title Your Last Rate of Pay

Your Reason For Leaving (please be specific)

Name of Employer Type of Industry

Employer's Location Phone

Dates of Employment (from Month/Year) (to Month/Year)

Your Job Title/Responsibility

Your Supervisor's Name & Title Your Last Rate of Pay

Your Reason For Leaving (please be specific)

Name of Employer Type of Industry

Employer's Location Phone

Dates of Employment (from Month/Year) (to Month/Year)

Your Job Title/Responsibility

Your Supervisor's Name & Title Your Last Rate of Pay

Your Reason For Leaving (please be specific)

Please explain any gaps in the previous Dates of Employment (from one employer to another) greater than three months.

How many days were you absent from work last year?

Do you ever take any illegal drug (such as, but not limited to, methamphetamine, marijuana, cocaine) without a medical prescription? Yes  No

NOTE: A “Yes” answer may not necessarily bar you from employment at Seneca.

If YES, please explain

Have you taken any illegal drug during the past year without a medical prescription? Yes  No

NOTE: A “Yes” answer may not necessarily bar you from employment at Seneca.

If YES, please explain

Have you ever been convicted of a felony (or have you agreed to a court settlement for a lesser crime after having been charged with a felony)? Yes No

If YES, please give date(s) and type(s) of crime(s), and you may provide any explanation you care to give.

NOTE: A “Yes” answer may not necessarily bar you from employment at Seneca.

Signature Required   Date

(For web application type your name)

We appreciate your interest in employment at Seneca.

Post Office Box 851 u Eugene, Oregon 97440

Phone (541) 689-1011 u FAX (541) 868-1430

7/17/07