City of Roseburg

Employment Application Form

Click here to download the Employment Application as a PDF

A job application is an important reflection on you. Make sure you emphasize the knowledge, skills, abilities, and employment experiences that best prepare you for the position which you are applying.

Please answer all questions. If the question does not apply to you or the position you are applying for, mark it "N/A". Resumes are accepted in addition to, not in lieu of, the application form.

Position Applying For

First Name

Middle Name

Last Name

Is any additional information relative to change of name, assumed name or nickname necessary to enable a check on your work or education history?

YesNo

If Yes, Explain

Physical Address

Street, City, State, Zipcode

Mailing Address

(if different than physical address)

Phone Number

123-456-7890

Cell Phone Number

If different than phone number

Are you eligible to work in the United States?

YesNo

Employees of the City of Roseburg must be at least 18 years of age. Are you able to meet this requirement?

YesNo

Please explain age exception.

Do you have any relatives currently employed by the City of Roseburg?

YesNo

Please provide name(s) and relationship(s)

EDUCATION RECORD

What is the highest grade completed or degree obtained? If currently in school, select your current grade.

Name of school where you completed your highest level of education

City and State

EMPLOYMENT HISTORY

Beginning with your present or most recent job, describe your work history and experiences related to the position for which you are applying.
Include all Military, Non-Paid or Volunteer work related to the position.

Please explain any interruptions in your employment record as described above

List any special training, licenses, certificates, machine skills, office equipment or other skills you may have that are pertinent to the position for which you are applying.

Acknowledgements

I certify that all of the information included in this application or supplied by me during the application process is true and complete. I understand that any false or misleading statement or omission of fact in this application or during the application process will disqualify me from further consideration for employment or will result in termination of my employment.

If I am hired, I agree to conform to all rules and regulations of the City. I understand that any offer of employment will not be enforceable unless it is in writing. If hired, I am able to present documents proving my identity and eligibility to work as required by federal law.

I understand that, as part of the City's employment procedures, I may be required to undergo testing carried out by a laboratory designated by the City. I consent to undergo any required drug testing. Finally, I understand that any offer of employment I might receive from the company may be made contingent upon, among other things, satisfactory completion of a post-offer medical examination and a determination by the City that I am capable of performing the essential functions of the position that has been offered, with or without reasonable accommodation.

I authorize investigation of all statements contained in this application and any other information about me relevant to my qualifications for employment. I hereby release and agree to indemnify and defend the City of Roseburg, its employees, officers, agents and representatives, from all liability, claims or damage resulting from this investigation."

YesNo

Veteran's Preference Eligibility

Are you eligible for Veteran's Preference?

YesNo

Veterans Preference Form

Under Oregon law, veterans who meet minimum qualifications for a position may be eligible for employment preference. If you think you may qualify, please read the following checklist carefully. Check the box for each item that is appropriate. If you need further explanation or have special circumstances, please call Human Resources at 541-492-6866. This completed form and required documentation must be submitted to the City of Roseburg Human Resources Department at the time you submit your employment application.

A. QUALIFIED VETERAN QUESTIONS

You may claim veteran’s preference if you check at least one box in each of the four sections below and provide proof of eligibility by submitting a copy of your DD-214 and 215.

I served on active duty with the Armed Forces of the United States for a period of more than 178 consecutive days and was discharged or released under honorable conditions; or

I served on active duty with the Armed Forces of the United States for 178 days or less and was discharged or released from active duty under honorable conditions because of a service-connected disability; or

I served on active duty with the Armed Forced of the United States for at least one day in a combat zone and was discharged or released from active duty under honorable conditions; or

I received a combat or campaign ribbon for service in the Armed Forces of the United States.

“Active duty” does not include attendance at a school under military orders, except schooling incident to an active enlistment or a regular tour of duty, or normal military training as a reserve officer or member of an organized reserve or a National Guard unit.

B. QUALIFIED DISABLED VETERAN QUESTIONS

You may claim additional employment preference if you can check at least one box in each of the three sections below and provide proof of eligibility by submitting both of the documents listed below
1. A copy of your DD 214 and 215, Certificate of Release or Discharge, Copy 4, and
2. A public employment preference letter from the United States Department of Veterans’ Affairs. To order the letter, call 1-800-827-1000 and request a public employment preference letter."

I am entitled to disability compensation under laws administered by the United States Department of Veterans Affairs; or

I was discharged or released from active duty for a disability incurred or aggravated in the line of duty; or

I was awarded the Purple Heart for wounds received in combat.

I hereby claim veteran’s preference points and certify that the above information is true and correct. I understand any false statements may be cause for my disqualification or dismissal, regardless of when discovered."

YesNo

ORS 408.225.230

Preference will not be awarded without the appropriate documentation. You must submit your DD-214 and 215 in all cases. If you are claiming disabled veteran points, you must also submit the public employment preference letter from the Department of Veterans Affairs. You will not receive preference without these accompanying documents.

SIGNATURE OF APPLICANT

VOLUNTARY

The following information is requested purely for statistical purposes. Responding to these questions is voluntary. Whether or not you choose to respond to the questions will not affect the status of your application.

Gender

Male

Female

Non-binary

Race/Ethnic Group

Hispanic

Asian

Black or African American

Native Hawaiian or other Pacific Islander

American Indian or Alaskan Native

White

Two or more races

Check if any of the following are applicable

Veteran

Disabled Veteran

Handicapped Individual

Eligible for Veteran Preference (Complete Veteran Preference Form above)

Where did you first learn about this employment opportunity?

City Website
Facebook
Indeed
LinkedIn
National Testing Network
Other (describe below)

Other