Employment Application

                     An Equal Opportunity Employer

OIC is an equal opportunity employer. This application will not be used for limiting or excluding any applicant from consideration for employment on a basis prohibited by local, state, or federal law. Applicants requiring reasonable accommodation in the application and/or interview process should notify an OIC representative.	

Please print and fill out all sections.  Incomplete applications may hinder consideration for employment.

Applicant Information	
Applicant Name		
	First name	Middle	Last name	
Address:					
	House Number	Street			
					
	City	State	Zip code	
Phone Number	Cell Phone	Email address	
Please list other names you have used:	
How were you referred to OIC of Washington?  	
Employment Interest	
Position(s) for 
which applying	1.	2.	3.	
Please explain why you are interested in this position and why you believe you are qualified for this position(s):

Type of Position Desired

     Temporary (summer or holiday)

     Part-time (less than 30 hours)

     Regular full time

     Contract position	Availability:

Daytime           Yes               No

Evenings         Yes               No

Weekends       Yes               No

Overtime         Yes               No	
Date available to start?	Salary desired:	
Background Information	
Have you worked for OIC before?         Yes         No	Date	Position	
Supervisor:	Reason for leaving	
Have you applied to OIC before?      Yes            No.  Date(s)	
Do you have any friends, relatives, significant other or acquaintances working for OIC?       Yes            No	
If yes, state name and relationship: 	
If hired, would you have transportation to and from work?        Yes           No	
Some positions require travel.  Do you have a valid driver’s license, reliable transportation and insurance?
   Yes            No	

Have you ever been under investigation for workplace misconduct; terminated for misconduct or been asked to resign in lieu of termination?      Yes          No.  If yes, please explain:

Are you 18 or older?      Yes         No  (If under 18, hire is subject to verification of minimum legal age). 	
If hired, would you be able to present evidence of your U.S. citizenship or proof of your legal right to work in the United States?      Yes            No	
If hired, are you willing to submit to and pass a controlled substance test?       Yes          No	
Are you able to perform the essential functions of the job for which you are applying, either with / without reasonable accommodation?       Yes          No   If not, please describe the functions that cannot be performed:

(Note: OIC complies with the ADA and will consider reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. It is possible that a hire may be tested on skill/agility and may be subject to a medical examination conducted by a medical professional).	
Have you ever been convicted of a criminal offense (felony or misdemeanor) or do you have any charges pending?      Yes            No.  If yes, please describe the crime, when and where convicted and disposition of the case:

(Note: Applicants will not be denied employment solely on the grounds of conviction of a criminal offense. The date of the offense, the nature of the offense, including any significant details that affect the description of the event, and the surrounding circumstances and the relevance of the offense to the position(s) applied for may, however, be considered). 	
Education Information (Please attach transcript or diploma)	

High School:	Name	Years completed	
	Address	Did you graduate?      Yes        No	
College/ University	Name	Years Completed	
	Address	Did you graduate?      Yes        No	
	Major and degree(s) earned	
Other Schools
(Vocational, Post graduate)	Name	Years completed	
	Address	Did you graduate?      Yes        No	
	Major and degree(s) earned	
Other Schools
(Vocational, Post graduate)	Name	Years Completed	
	Address	Did you graduate?      Yes        No	
	Major and degree(s) earned	
Military Service Information (If applicable)	
Branch	Rank	Years of service	
Skills/duties	Type of Discharge	Are you a Viet Nam era Veteran? 
    Yes           No	
Language Skills Information	
Please list any foreign languages you speak with proficiency:

Spoken ability:     Fluent        Good         Minimal
	Written ability:     Fluent        Good         Minimal
	
Additional Skills and Experience Information	
Please document other experience, training, qualifications, or skills which you feel should be brought to our attention, in the case that they make you especially suited for working with us? 

	
Employment History	
List all present and past employment positions, dating back 10 years. List the most recent positions first.  Even if you have attached a resume, this section must be completed.  Account for all periods of unemployment. 	
Are you currently employed?      Yes            No	
Name of last or present employer	May we contact them for references?     Yes          No	
Position(s)		Dates of Employment	
Reason for leaving	Name of Supervisor  	
Telephone Number:      	Salary	
Address	
Name of next most recent employer	May we contact them for references?     Yes          No	
Position(s)		Dates of Employment	
Reason for leaving	Name of Supervisor  	
Telephone Number:      	Salary	
Address	
Name of employer	May we contact them for references?     Yes          No	
Position(s)		Dates of Employment	
Reason for leaving	Name of Supervisor  	
Telephone Number:      	Salary	
Address	
Name of employer	May we contact them for references?     Yes          No	
Position(s)		Dates of Employment	
Reason for leaving	Name of Supervisor  	
Telephone Number:      	Salary	
Address	
Name of employer	May we contact them for references?     Yes          No	
Position(s)		Dates of Employment	
Reason for leaving	Name of Supervisor  	
Telephone Number:      	Salary	
Address	
Please explain any gap in employment: 	

Professional References	
List below three persons who have knowledge of your work performance within the last four years.  Please include professional references only and do not include names of relatives. 
	
Name		Telephone number	
Address		
	Number and street	City	State	Zip	
Occupation		Number of years acquainted:	
Name		Telephone number	
Address		
	Number and street	City	State	Zip	
Occupation		Number of years acquainted:		
Name		Telephone Number	
Address		
	Number and street	City	State	Zip	
Occupation		Number of years acquainted:	
Acknowledgement	
Please read and initial each paragraph, then sign below

I attest to the fact that the answers given by me are true and correct to the best of my knowledge and ability.  I further certify that I have not purposely withheld any information that might adversely affect my chances for hiring.  I understand that any omission (including any misstatement) of material fact on this application or on any document used to secure employment or benefits can be grounds for rejection of my application or, if I am employed by OIC, it may be grounds for my immediate termination from OIC regardless of the time elapsed before discovery.  _____ 

I understand that if I am employed, that OIC of Washington is an at-will employer and that nothing contained in the application, during any interview which may be granted or during my employment (if I am hired), is intended to create an employment contract between me and OIC.  In addition, I understand and agree that if I am employed, my employment is not for any definite period and may be terminated at any time or any reason with or without prior notice, at the option of OIC or me, and that no promises or representation contrary to the foregoing are binding on OIC unless made in writing and signed by the CEO and me.

I understand that the continuation of all positions is contingent on continued funding.   _____.

I authorize OIC to examine my references, record of employment, education record and any other information I have provided. I authorize the references I have listed to disclose any information related to my work record and my professional experiences with them, without giving me prior notice of such disclosure. In addition, I release OIC of Washington, my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such examination or revelation _____. 

	
Applicant's Signature	Date	

OIC Application 1/3/2011
<html><head><meta http-equiv="Content-Type" content="text/html; charset=windows-1252"><title>Equal Opportunity Tag Line</title><meta name="GENERATOR" content="Microsoft FrontPage 6.0"><meta name="ProgId" content="FrontPage.Editor.Document"></head><body topmargin="0"><div align="center">	<table border="0" width="700" cellspacing="10" style="font-family: Arial; font-size: 10pt; color: #006600" id="table1">		<tr>			<td>OIC of Washington is an equal opportunity employer and provider 			of employment and training services. <!-- OIC does not discriminate against 			any employee, applicant or participant due to race, creed, color, 			national origin, sex, age, marital status, religion, or physical, 			mental or sensory disability. -->Auxiliary aids and services are 			available upon request to individuals with disabilities.<br>			<br>			Washington Relay Service: 1-800-833-6388</td>		</tr>		<tr>			<td>			<p align="left"></td>		</tr>		<tr>			<td align="center">			<table border="0" width="100%" id="table2">				<tr>					<td><font color="#FFFFFF">_________________________</font></td>					<td><div id="google_translate_element"></div><script>function googleTranslateElementInit()   new google.translate.TranslateElement(    pageLanguage: 'en'  , 'google_translate_element');</script><script src="//translate.google.com/translate_a/element.js?cb=googleTranslateElementInit"></script>			</td>					<td>&nbsp;</td>				</tr>			</table>			</td>		</tr>	</table></div><p>&nbsp;</p><p>&nbsp;</p></body></html>