Employment at East Portland Care Please use the application form below: Click here for our ONLINE EMPLOYMENT APPLICATION Position applied for:*Date of Application Date Format: MM slash DD slash YYYY Expected wage:Are you under the age of 18?YesNoPERSONAL INFORMATION:Name* First Last Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Driver's License #*Home Phone Number:*Cell Phone Number:*Email Address:* Social Security Number:*Have you ever worked for Sapphire Living Inc. in the past?*YesNoIf yes, when and where?EDUCATIONHigh School:Highest year completed: 9, 10, 11, l2/Diploma?Address City State / Province / Region ZIP / Postal Code College or Technical School 1:Address City State / Province / Region ZIP / Postal Code Did you graduate?YesNoDegree level:Major:College or Technical School 2:Address City State / Province / Region ZIP / Postal Code Did you graduate?YesNoDegree level:Major:LICENSURE AND CERTIFICATIONType:State of Issue:Expiry Date: Date Format: MM slash DD slash YYYY Type:State of Issue:Expiry Date: Date Format: MM slash DD slash YYYY Type:State of Issue:Expiry Date: Date Format: MM slash DD slash YYYY Type:State of Issue:Expiry Date: Date Format: MM slash DD slash YYYY EMPLOYMENT HISTORYName of Company 1:Address City State / Province / Region ZIP / Postal Code PhoneStart Date: Date Format: MM slash DD slash YYYY End Date: Date Format: MM slash DD slash YYYY Ending Pay Rate:Reason for Leaving:Ending Position:Name of Company 2:Address City State / Province / Region ZIP / Postal Code PhoneSupervisor/Manager:Start Date: Date Format: MM slash DD slash YYYY End Date: Date Format: MM slash DD slash YYYY Ending Pay Rate:Reason for Leaving:Ending Position:Have you ever been discharged from employment or resigned in lieu of termination?*YesNoIf yes, please explain:Additional Experience or Qualifications:BUSINESS & PERSONAL REFERENCES <br> (List business references first)Name:Occupation:PhoneName:Occupation:PhoneName:Occupation:PhoneName:Occupation:PhoneAttach your Resume: Note : Sapphire Living Inc. is committed to equal employment ln all of its employment practices. Decisions involving every aspect of the employment relationship are made without regard to an employee's race, color, creed, religion, gender, sexual orientation, age, national origin, marital status, veteran status, worker compensation, disability, or any other status or characteristic protected under applicable state or federal law, unless it is a bona fide occupational requirement necessary to the normal operation of the business. NOTIFICATION & AGREEMENT Please read carefully; answer each question and sign at the bottom. Your application will become valid only when you sign and date it. If you have any questions regarding these statements, please ask them before signing: Your application will be given every consideration but its receipt does not imply you will be employed. Your signature authorizes Sapphire Living Inc. to seek and obtain a report from the State of Oregon or Washington, Motor Vehicle Records Department. Your signature also authorizes Sapphire Living Inc. to obtain state or federal background check information as required to work with vulnerable persons. It is understood that should background Information be obtained that is untoward, an offer of employment will not be given, or may be rescinded. AGREEMENT I understand the following: Sapphire Living Inc. may elect to engage an investigative consumer reporting agency to discover and report on my credit and personal history. If such a decision is made, the company will provide me with further required Information: and that my signature on this application gives the employer authority to engage such and agency. I certify that all answers and statements I have made on this application, and any other accompanying required • documents are true and complete without omissions. I understand that any falsifications, misrepresentations or omission of fact on this application or any other accompanying or required documents will be cause for denial of employment or immediate termination of employment regardless of when or how discovered. I understand that my employment may be subject to the satisfactory results of any examination required by this facility, including a mandatory urine test to detect drug usage and hereby submit to said testing. I agree to conform to all rules and regulations of the company as they presently exist or are later modified. l recognize that my employment is at will and may be terminated at the discretion of the company or at option, without notice. I understand that nothing contained in this employment application or in the grant if of an interview is intended to create a contract between this facility and myself for employment for any specified period of time, or to assure me of any future position, benefits, or terms and conditions of employment. I acknowledge that 1 have read, understand, and agree with the above. In addition, I hereby authorize any of the persons • of the organizations named in the application, or any other accompanying or required documents to give you complete information and records regarding my employment, education, character and qualifications. This application is only valid for the position being applied for. Do you agree to the above terms?YesNoDate Date Format: MM slash DD slash YYYY
