COOS COUNTY APPLICATION FOR EMPLOYMENT

1. Position applying for ________________________________ Department__________________________

2. Name_____________________________________________Social Security No.___________________
                  Last                                First                               MI

3. Mailing Address_______________________________________________________________________
                                          Street/PO Box                         City                       State                  Zip                                    Telephone

4. Have you ever been convicted of a crime? ( ) Yes ( ) No. (Exclude those cases processed in juvenile court
and minor traffic violations.) Conviction does not necessarily disqualify you from employment. If yes, explain.

______________________________________________________________________________________

______________________________________________________________________________________

5. EDUCATION RECORD:
Did you graduate from High School? ( ) Yes ( ) No. If no, do you have your GED? ( ) Yes ( ) No

COLLEGE, TRADE SCHOOL OR SPECIAL TRAINING RECEIVED:

_______________________________________________________________________________________
Name and location         From-To (Mo/Yr)       Fields of Study (Major/Minor)       Credit (Semester/Qtr. Hrs.)         Certificates/Degrees etc.

_________________________________________________________________________
Name and location         From-To (Mo/Yr)       Fields of Study (Major/Minor)       Credit (Semester/Qtr. Hrs.)         Certificates/Degrees etc.

_________________________________________________________________________
Name and location         From-To (Mo/Yr)       Fields of Study (Major/Minor)       Credit (Semester/Qtr. Hrs.)         Certificates/Degrees etc.

6. List any special skills, additional training, licenses or certificates you have that are pertinent to the position
for which you are applying. _______________________________________________________________________________________

Typing speed ___________wpm                                            Shorthand or Speedwriting ______________wpm

7. REFERENCES: List the names of three persons other than former employers and relatives having knowledge
of your character, experience or ability.

1.______________________________________________________________________________________
    Name                                                          Address                                              Business                                        Telephone      

2.______________________________________________________________________________________
    Name                                                          Address                                              Business                                        Telephone      

3.______________________________________________________________________________________
    Name                                                          Address                                              Business                                        Telephone      

8. Do you have any relative(s) currently employed by the County? ( ) Yes ( ) No. If yes, give name(s) and relation.
_______________________________________________________________________________________

9. If applying for a position which requires you to drive, please complete the following:
Possess a valid Oregon Driver's License? ( ) Yes ( ) No. ODL # _______________. Has license been restricted,
suspended or revoked in the last 5 years? ( ) Yes ( ) No. If yes, explain.

_______________________________________________________________________________________

10. EMPLOYMENT HISTORY - Beginning with your PRESENT or MOST RECENT job, describe your work experience during the past EIGHT years. In addition, list any other prior experience related to the duties of the position for which you are applying. Include volunteer work.
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______________________________________________________________________________________
Employing Firm & Address                             Phone Number                       Your Job Title                                Supervisor's Name & Title

________________________________( ) Yes ( ) No  $_________________________________________
From: Mo. - Yr.                To: Mo. - Yr.                           Full Time              Last Salary                                    Reason for leaving

Specific Duties __________________________________________________________________________

______________________________________________________________________________________
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______________________________________________________________________________________
Employing Firm & Address                             Phone Number                       Your Job Title                                Supervisor's Name & Title

________________________________( ) Yes ( ) No  $_________________________________________
From: Mo. - Yr.                To: Mo. - Yr.                           Full Time              Last Salary                                    Reason for leaving

Specific Duties __________________________________________________________________________

______________________________________________________________________________________
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______________________________________________________________________________________
Employing Firm & Address                             Phone Number                       Your Job Title                                Supervisor's Name & Title

________________________________( ) Yes ( ) No  $_________________________________________
From: Mo. - Yr.                To: Mo. - Yr.                           Full Time              Last Salary                                    Reason for leaving

Specific Duties __________________________________________________________________________

______________________________________________________________________________________
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______________________________________________________________________________________
Employing Firm & Address                             Phone Number                       Your Job Title                                Supervisor's Name & Title

________________________________( ) Yes ( ) No  $_________________________________________
From: Mo. - Yr.                To: Mo. - Yr.                           Full Time              Last Salary                                    Reason for leaving

Specific Duties __________________________________________________________________________

______________________________________________________________________________________

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______________________________________________________________________________________
Employing Firm & Address                             Phone Number                       Your Job Title                                Supervisor's Name & Title

________________________________( ) Yes ( ) No  $_________________________________________
From: Mo. - Yr.                To: Mo. - Yr.                           Full Time              Last Salary                                    Reason for leaving

Specific Duties __________________________________________________________________________

______________________________________________________________________________________
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11. REMARKS - Use this space for additional details and clarification. You may also attach any additional information, i.e., resume, letters of recommendation.

_________________________________________________________________________________________

___________________________________________________________________________

12. I understand that to insure that I am not placed in a position which might be a hazard to me or to others, a physical examination or other forms of testing relating to my physical condition may be required upon offer of employment at Coos County's expense and authorize release of information to Coos County, and I release Coos County from any and all liability related to the examination and/or testing.

I certify that the facts and information in this application and in any attachments or supporting documents are true and complete to the best of my knowledge. I understand that any falsification, misrepresentation or omission, as well as any misleading statements or omissions, will be cause for denial of employment or immediate termination, regardless of when or how discovered.

I authorize the investigation of all matters which Coos County deems relevant to my qualifications for employment, including all statements contained in this application and in any attachments or supporting documents. I authorize you to request and receive such information and I release from all liability any persons (such as former supervisors and managers) or employers supplying it. I also release Coos County from all liability which might result from making the investigation.

I have read the above statements and have reviewed all of the information I provided in this application and in any attachments or supporting documents.

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As an Equal Opportunity/Affirmative Action Employer, Coos County is dedicated to a policy of non-discrimination in employment on the basis of race, color, religion, sex, national origin, age, marital status, mental or physical disability.

Under provision of the Immigration Reform and Control Act of 1986, Coos County requires any person hired or rehired to provide evidence of identity and eligibility for employment.

NOTE: If you believe your civil rights in employment matters have been violated at any time during the course of your consideration for employment, please contact the Personnel Office.