Oregon Manor & Main Street Quarters

Your application will not be processed unless you have read and signed the following authorization, release and certification statement.

Authorization, release and certification

I certify that all information on this application is true, complete and correct to the best of my knowledge. I understand that any false or misleading statements by me, or material omission of information requested of me, may result in refection of my application or, if employed, my immediate dismissal.

I hereby give permission to the employer to seek to verify and supplement the information set forth in the application. I release formally liability or legal claims every person seeking or providing information, whether oral or written. A photocopy of this release shall be as valid as the original and may be relied upon by all persons providing information.

I understand that if offered employment, such offer may be conditioned of the results of a pre-employment physical examination (including a tuberculin skin test).

I understand that all employment with this employer is at-will employment. As an at-will employee, I understand and agree that, if hired, I may voluntarily leave employment at any time and may be terminated at any time without prior notice for any or no reason. I understand that any oral or written statements which I may claim to have been made to me now or in the future inconsistent with the provisions of this paragraph, are expressly disavowed and revoked by the company and should not be relied upon by me as applicant for employment or as an employee, if hired.

I understand this application will be considered inactive after thirty (30) days.

I certify I have read (or have had read to me) and understand this authorization, release and certification.

Oregon Manor is an equal opportunity employer and does not discriminate. Applications will remain effective for a period of thirty (30) days from the date submitted.

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Personal Information:
*First Name:
*Last Name:
Middle Name:
*Application Date:
*Address:
*City:
*State:
*Zip Code:
*Primary Phone Number:
Mobile Number:
*Are you 18 years or older?	Yes No
*Date of Birth:
*E-mail Address:
*Are you a U.S. citizen or otherwise authorized to obtain lawful employment in this country?	Yes No
Employment Desired:
*Position(s):
*Date you can start:
Desired Wage:
*You are available to work:	Full-time Part-time Temporary
*Have you applied to this company before?	Yes No

Education and Training: This information will be used only where relevant and to assist in determining what positions might be appropriate for consideration.
Education - High School
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Did you graduate from high school?	Yes No
Subjects Studied:

Education - College
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If so, what was your major?
Subjects Studied:

Education - Trade/Business
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Education - Training, Special Skills or QualificationsDescribe any other training, special skills or qualifications you consider relevant to the position for which you are applying required from employment, volunteer or organizational activities.

Education - Licensure or CertificationList any licensure or certification that you consider relevant to the position(s) you are applying for [include relevant dates, license or certification number, etc.]


Work Experience/Former Employees: Provide complete information. Be specific. Start with your current or most recent job.Include self-employment and military service. Show any changes in job title for the same employer as a separate position.
*Are you employed now?	Yes No
*If so, may we contact your present employer?	Yes No
Employer #1
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Employer #2
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Employer #3
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References Persons not related to you. Reference #1
*Reference #1 Name:
*Reference #1 Address:
*Reference #1 Telephone number:
*Business:
*Years Acquainted:
Reference #2
*Reference #2 Name:
*Reference #2 Address:
*Reference #2 Telephone number:
*Business:
*Years Acquainted: