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