First Name *

Last Name *

Email *

Phone *

Address

State

City

Postal code

Previous Address if less than 5 years at the current address (City, State) *

Have you been terminated or asked to resign? If yes, provide details. *

Yes

No

Details (if yes)

Have you pled guilty or "no contest" to a crime, been convicted of a crime, had adjudication withheld or prosecution deferred? If yes, please give date and details. (Conviction record may not necessarily prohibit employment. Factors such as date, nature and offense will be considered) *

Have you been a defendant in a suit such as assault, battery, false imprisonment, wrongful death? If yes, please give date and details. *

Minimum pay rate $ *

Position Applying For *

Date available to start *

How did you learn about our company and/or position? If employee referral, provide name: *

Are you willing to relocate within 35 miles of the Umpqua Sheet Metal office location? *

Yes

No

Are there days or hours you would be unable to work? *

Yes

No

If yes, when?

Will you be able to work overtime? *

Yes

No

Will you be able to travel within Oregon? *

Yes

No

Have you applied with our company before? *

Yes

No

If yes, when?

Have you been employed by Umpqua Sheet Metal? *

Yes

No

If yes, when?

Reason for Leaving?

High School Name *

High School City/State *

Graduated? *

Yes

No

GED? *

Yes

No

College Name *

College City/State *

Years Completed *

Years Completed

Graduate School Name *

Graduate School City/State *

Graduate School Years Completed *

Graduate School Years Completed

Are you planning on Continuing Education? *

Yes

No

If yes, when, where and what courses?

List any educational honors and activities involved in during school *

List and describe specialized training *

Professional License *

Certification *

Some positions require reporting to different job sites. Reliable transportation is necessary. Will you be able to report on a regular consistent basis? If no, explain *

Do you have a valid driver's license issued in Oregon? *

Yes

No

Any history of license restrictions? If yes, explain *

Reference 1 Name *

Reference 1 City *

Reference 1 Phone *

Reference 1 Occupation *

Reference 2 Name

Reference 2 City

Reference 2 Phone

Reference 2 Occupation

Reference 3 Name

Reference 3 City

Reference 3 Phone

Reference 3 Occupation

Employer 1 *

Previous Position 1 *

City, State 1 *

Employer 1 Telephone *

Employer 1 - Supervisor's Name *

Employer 1 Starting Salary *

Employer 1 Ending Salary *

Employer 1 Start Date (mo/yr) *

Employer 1 End Date (mo/yr) *

Employer 1 Duties *

Employer 1 - What did you like most about your job? *

Reason for leaving Employer 1 *

Eligible for Re-hire with Employer 1? *

Yes

No

Employer 2

Previous Position 2

City, State 2

Employer 2 Telephone

Employer 2 - Supervisor's Name

Employer 2 Starting Salary

Employer 2 Ending Salary

Employer 2 Start Date (mo/yr)

Employer 2 End Date (mo/yr)

Employer 2 Duties

Employer 2 - What did you like most about your job?

Reason for leaving Employer 2

Eligible for Re-hire with Employer 2?

Yes

No

Employer 3

Previous Position 3

City, State 3

Employer 3 Telephone

Employer 3 - Supervisor's Name

Employer 3 Starting Salary

Employer 3 Ending Salary

Employer 3 Start Date (mo/yr)

Employer 3 End Date (mo/yr)

Employer 3 Duties

Employer 3 - What did you like least about your job?

Reason for leaving Employer 3

Eligible for Re-hire with Employer 3?

Yes

No

If you worked using another name, please list name(s) here. List previous name 1, and at which company *

List previous name 2, and at which company *

Are you currently employed? *

Yes

No

If yes, may we contact your present employer?

Yes

No

Have you been disciplined, warned, demoted, suspended, placed on probation or terminated? If yes, explain *