Prospective employees will receive consideration without discrimination based on race, creed, color, sex, age, national origin, veteran status, marital status, disability, handicap, sexual orientation, citizenship status or any condition prescribed by state or local law
Oregon Urology Institute

APPLICATION FOR EMPLOYMENT
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Last Name* First* Middle
E-mail* Repeat E-mail*
Date: (e.g. 01/01/2018)
Street Address
 Home Telephone*
City, State, Zip*
 Business or Cell Telephone
Have you ever applied for employment with us?
Yes No
 How did you hear about this job opening?
   
Position Desired Job ID License/Certification Number
 
Location*
OUI OSC
Apart from religious observance, are you available for full-time work?
Yes No
 Will you work overtime if asked?
Yes No
Are you legally eligible to work in the United States?
 When will you be available to begin work? (e.g. 01/01/2018)
Have you ever been bonded?

Yes No
Other special training, skills or languages.
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N 		School Name and Location of School Course of Study No. of
Years
Completed		 Did you
Graduate?		 Degree or
Diploma		 Graduation Year
Graduate Yes
No
College Yes
No
Business /
Trade /
Technical		 Yes
No
High School Yes
No
EMPLOYMENT Please give accurate, complete, full-time and part-time employment record. Start with your present or most recent employer.
1 Company Name
 Telephone
Address
Full Time Part Time Per Diem
Employed - (State month and year)
From To
Name of Supervisor
State Job Title
Describe Your Work
 Reason for Leaving
We may contact the employers listed above unless you indicate those you do not want us to contact DO NOT CONTACT
Employer Number(s)

Reason
Military Did you serve in the U.S. Armed Forces? Yes No
Describe any training received relevant to the position for which you are applying
Additional Information
Membership in professional and civic organizations, special accomplishments, awards, etc.
(Exclude those which may disclose your race, color, religion, age or national origin)
Applicant's Signature
Please read and understand this statement before signing your application:


The information I have provided in this Application for Employment is true, correct and complete. False, incomplete or misrepresented information of any kind, will be sufficient cause for my application to be rejected or, if discovered after I am employed, cause for immediate termination of my employment.

I authorize the employer to contact and obtain information about me from previous employers, educational institutions and "references" I provided, and any other party necessary to verify the accuracy of information I disclosed in this application, a related employment resume or a personal interview. To assist in the processing of my Application, I waive all rights and claims I may otherwise have against the employer or its representatives, for seeking, and using information to evaluate my employment request and all other persons, corporations or organizations who provide information for this purpose.

This application will expire in 30 days. After that date, unless otherwise notified, I understand that my status as an applicant will end. I may re-apply for employment or organizations who provide information for this purpose

This application is not an employment agreement. If I accept an offer of employment I understand the employer may terminate my employment at any time, with or without cause and without prior notice, unless required by law. I understand that no one, other than an executive officer of the employer, has authority to enter into any employment agreement with terms contrary to the foregoing and then only in writing signed by such officer.

Drug Screen Notice

While the use of marijuana is authorized under state laws, marijuana is illegal under federal law and therefore is considered an illegal and/or unauthorized controlled substance in policies of Oregon Urology Institute and Oregon SurgiCenter . Accordingly, having any detectable level of marijuana in your system when completing your pre-employment drug screen will be considered a failed test and make you ineligible to be hired.
I fully understand and accept all terms and conditions in the above statement

Date: (e.g. 01/01/2018)Signature:*