Details for Application
345 NE Winchester St. Roseburg, OR 97470 APPLICATION FOR EMPLOYMENT (PRE-EMPLOYMENT QUESTIONNAIRE) (AN EQUAL OPPORTUNITY EMPLOYER) PERSONAL INFORMATION DATE NAME LAST FIRST MIDDLE Address STREET CITY STATE ZIP STREET CITY STATE ZIP Mailing Address (IF DIFFERENT) E-Mail address: Primary Phone: ( ) - Secondary Phone: ( ) - Best time to call: Are you at least 18 years of age? _____YES _____NO Referred to the News-Review by--- EMPLOYMENT DESIRED Position Are you employed now? If so, can we contact your current employer? Y N Y N Type of employement desired: ___Full time ___Part time ____Temporary Date Available for Work Start Desired Wage: Do you have a valid Driver's License? Y Have you ever been employed at the News-Review before? Y Will you work overtime if required by the job? Y N N When? N NOTE: Some positions may require drug testing and/or drivers record history request EDUCATION NAME AND LOCATION OF SCHOOL MAJOR GRADUATED? Degree? HIGH SCHOOL Y N Y N COLLEGE Y N Y N TRADE SCHOOL Y N Y N *The Age Discrimination in Employment Act of 1967 prohibits discrimination on the basis of age. U.S. MILIT OR NAVAL SERVICE: RANK: PRESENT MEMBERSHIP IN NATIONAL GUARD OR RESERVES Lotus Media Group LLC dba The News-Review Application - Rev 02-2017 Page 1 of 3 EMPLOYMENT HISTORY (Starting with most recent, list below last four employers) Dates employed Month/Year NAME/ADDRESS/PHONE OF EMPLOYER POSITION REASON FOR LEAVING FROM TO Immediate Supervisor: May we contact: Y N Summarize the type of work performed: Starting Wage: Ending Wage: FROM TO Immediate Supervisor: May we contact: Y N Summarize the type of work performed: Starting Wage: Ending Wage: FROM TO Immediate Supervisor: May we contact: Y N Summarize the type of work performed: Starting Wage: Ending Wage: FROM TO Immediate Supervisor: May we contact: Y N Summarize the type of work performed: Starting Wage: Ending Wage: Explain any gaps in your employment, other than those due to personal illness, injury or disability If not addressed above, have you ever been fired or asked to resign from a job? Y N If yes, please explain: Is there any information you would like to provide regarding the News-Review running a background check? Lotus Media Group LLC dba The News-Review Application - Rev 02-2017 Page 2 of 3 SKILLS AND QUALIFICATIONS Summarize any special training, skills, licenses and/or certifications that may assist you in performing the position for which you are applying REFERENCES List names and telephone numbers of three (3) business/work references who are not related to you and are not previous supervisors. If not applicable, list three school or personal references who are not related to you. Name Address-----Phone Number Business/relationship to you Years Known DO YOU HAVE ANY PHYSICAL LIMITATIONS THAT PRECLUDE YOU FROM PERFORMING ANY WORK FOR WHICH YOU ARE BEING CONSIDERED? YES NO Can you provide documentation, if hired, of your legal right to work in the United States? YES NO Applicant Statements (Check all boxes) I certify that all information I have provided in order to apply for and secure work with this employer is true, complete and correct. I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references, employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives, for seeking, gathering and using truthful and non-defamatory information, in a lawful manner, in the employment process and all other persons, corporations or organizations for furnishing such information about me. I understand that this employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or eliminating any applicant from consideration for employment on any basis prohibited by applicable local, state or federal law. Employment by the News-Review is at will and is at the mutual consent of the employee and the employer. Consequently, either the employee or the employer can terminate the employment relationship at any time, with or without advance notice. The application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the employers General Manager. I also understand that if I am hired, I will be required to provide proof of identity and legal authorization to work in the United States and that federal immigration laws require me to complete an I9 Form in this regard. The News-Review does not tolerate unlawful discrimination in its employment practices. No question on this application is used for the purpose of limiting or excluding an applicant from consideration for employment on the basis of his/her sex, race, color, religion, national origin, genetic information, citizenship, age, disability or any other protected status under local, state or federal law. Likewise, The News-Review does not tolerate harassment based on sex, race, color, religion, national origin, citizenship, genetic information, age disability, or any other protected status. Harassment of our employees is strictly prohibited; whether it is committed by a manager, co-worker, subordinate or non-employee. The NewsReview takes all complaints of harassment seriously and all complaints will be investigated promptly and thoroughly. I understand that any information by me that is found to be false, incomplete or misrepresented in any respect will be sufficient cause to i) eliminate me from further consideration for employment or ii) may result in my immediate discharge from the employer's service, whenever it is discovered. I certify that I have read, fully understand and accept all terms of this Applicant Statement. I understand that I am required to submit a complete application, and that my failure to do so may result in disqualification from consideration for the position. DATE Lotus Media Group LLC dba The News-Review SIGNATURE Application - Rev 02-2017 Page 3 of 3
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