Employment Application

Personal Information

First Name *

MI *

Last Name *

Street Address *

City *

State *

Zip Code *

Phone Type *

Phone Number *

Phone Type

Additional Phone Number

Email Address *

Driver License # *

Issuing State *

How did you hear about us? *

Employee Name *

Employment Desired

Desired Position *

Have you ever applied to this company before? *

Yes

No

Industry standards dictates that you must be at least 24 years of age. Are you at least 24 years old? *

Yes

No

Industry standards dictates that you must be at least 24 years of age. Are you at least 24 years old? *

Yes

No

Industry standards dictates that you must be at least 18 years of age. Are you at least 18 years old? *

Yes

No

Date available to start: * +

Are you currently employed? *

Yes

No

May we contact your current employer? *

Education History

	Name of school	Years attended	Did you graduate	Subjects studied
High School	Name of school	Years attended	Did you graduate	Subjects studied
College	Name of school	Years attended	Did you graduate	Subjects studied
Trade School	Name of school	Years attended	Did you graduate	Subjects studied

Employment History

Employer Name

Position Held

Start Date +

End Date +

Reason for Leaving

Employer Name

Position Held

Start Date +

End Date +

Reason for Leaving

Employer Name

Position Held

Start Date +

End Date +

Reason for Leaving

References

Name *

Email Address *

Relationship *

Years Known *

Name *

Email Address *

Relationship *

Years Known *

Name *

Email Address *

Relationship *

Years Known *

I authorize ODEC Medical Transport to check my references, to obtain information from my previous employers, and to take other actions to investigate any information provided in my employment application, and to obtain information relevant to evaluating my qualifications and fitness for a non-emergency medical driver with ODEC Medical Transport. I authorize my listed references and past employers, and anyone else who has information about my work history, qualifications, or fitness to provide such information ODEC Medical Transport for which I have completed an employment application. *

I Agree

I authorize Oregon Driver Education Center to check my references, to obtain information from my previous employers, and to take other actions to investigate any information provided in my employment application, and to obtain information relevant to evaluating my qualifications and fitness for this position with ODEC. I authorize my listed references and past employers, and anyone else who has information about my work history, qualifications, or fitness to provide such information Oregon Driver Education Center for which I have completed an employment application. *

I Agree

I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that , if employed, falsified statements on this application are shall be grounds for dismissal. Submitting this application does not guarantee employment. *

I Agree

Please attach cover letter *

Please attach resume *

Electronic Signature *

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