Employment Application – Center for Continuous Improvement, Inc.

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Personal Information

NAME (LAST NAME, FIRST NAME, MIDDLE NAME) *

ADDRESS *

APT. NO.

CITY *

STATE *

ZIP *

PHONE NUMBER *

PREFERRED PRONOUNS

HAVE HIGH SCHOOL DIPLOMA OR EQUIVALENT? *

Yes
No

Email

Desired Employment

POSITION *

DATE YOU CAN START

WAGE DESIRED

ARE YOU EMPLOYED NOW?

Yes
No

IF SO, MAY WE INQUIRE OF YOUR PRESENT EMPLOYER?

Yes
No

EVER APPLIED TO THIS COMPANY BEFORE?

Yes
No

WHERE?

DATE?

EVER WORKED FOR THIS COMPANY BEFORE?

Yes
No

WHERE?

DATES?

REASON FOR LEAVING

NAME OF LAST SUPERVISOR AT THIS COMPANY

WHO REFERRED YOU TO THIS COMPANY?

WHO REFERRED YOU TO THIS COMPANY?

NEWSPAPER
WALK-IN
CRAIGS LIST
INDEED.COM
FRIEND
STATE EMPLOYMENT AGENCY
SCHOOL PLACEMENT SERVICE

OTHER REFERRAL

IF HIRED, CAN YOU PRESENT EVIDENCE OF YOUR US CITIZENSHIP OR PROOF OF YOUR LEGAL RIGHT TO LIVE AND WORK IN THIS COUNTRY?

Yes
No

CAN YOU PERFORM THE ESSENTIAL FUNCTIONS FOR THE JOB APPLIED FOR AS LISTED IN THE JOB DESCRIPTION, WITH OR WITHOUT REASONABLE ACCOMODATIONS?

Yes
No

(IF NO, DESCRIBE THE ESSENTIAL FUNCTIONS THAT CANNOT BE PERFORMED.)

IF HIRED, WOULD YOU HAVE A RELIABLE MEANS OF TRANSPORTATION TO AND FROM WORK?

Yes
No

Education

HIGH SCHOOL – NAME AND LOCATION

HIGH SCHOOL – NUMBER OF YEARS COMPLETED

HIGH SCHOOL – DID YOU GRADUATE?

Yes
No

HIGH SCHOOL – LIST DEGREE/DIPLOMA OR GED

COLLEGE – NAME AND LOCATION

COLLEGE – NUMBER OF YEARS COMPLETED

COLLEGE – DID YOU GRADUATE?

Yes
No

COLLEGE – LIST DEGREE/DIPLOMA OR GED

VOCATIONAL/BUSINESS SCHOOL – NAME AND LOCATION

VOCATIONAL/BUSINESS SCHOOL – NUMBER OF YEARS COMPLETED

VOCATIONAL/BUSINESS SCHOOL – DID YOU GRADUATE?

Yes
No

VOCATIONAL/BUSINESS SCHOOL – LIST DEGREE/DIPLOMA OR GED

HEALTH CARE TRAINING – NAME AND LOCATION

HEALTH CARE TRAINING – NUMBER OF YEARS COMPLETED

HEALTH CARE TRAINING – DID YOU GRADUATE?

Yes
No

HEALTH CARE TRAINING – LIST DEGREE/DIPLOMA OR GED

Employment History

List below all present and past employment starting with your most recent employer. Do not omit any employers. Explain any gaps in employment in the space provided.

NAME OF PRESENT OR LAST EMPLOYER

ADDRESS

CITY

STATE

ZIP

LEAVING DATE

STARTING DATE

JOB TITLE

MAY WE CONTACT THIS EMPLOYER?

Yes
No

(we will contact past employers to verify previous employment)

NAME OF SUPERVISOR

TITLE

PHONE

DESCRIPTION OF WORK

REASON FOR LEAVING

NAME PREVIOUS OF EMPLOYER 1

ADDRESS

STATE

ZIP

STARTING DATE

LEAVING DATE

JOB TITLE

MAY WE CONTACT THIS EMPLOYER?

Yes
No

(we will contact past employers to verify previous employment)

NAME OF SUPERVISOR

TITLE

PHONE

DESCRIPTION OF WORK

REASON FOR LEAVING

NAME PREVIOUS OF EMPLOYER 2

ADDRESS

CITY

STATE

ZIP

STARTING DATE

LEAVING DATE

MAY WE CONTACT THIS EMPLOYER?

Yes
No

(we will contact past employers to verify previous employment)

NAME OF SUPERVISOR

TITLE

PHONE

DESCRIPTION OF WORK

REASON FOR LEAVING

EXPLANATION FOR GAPS OF EMPLOYMENT

Driving Information

Complete this only if the position you are applying for requires driving as an essential duty.

DO YOU HAVE ANY CURRENT DRIVING RESTRICTIONS?

Yes
No

DO YOU HAVE A VALID DRIVER’S LICENSE?

Yes
No

IF YES, LIST DRIVERS LICENSE NUMBER AND CLASS

WHAT STATE ARE YOU LICENSED IN?

WHAT DRIVING INFRACTIONS HAVE YOU HAD DURING THE LAST 5 YEARS?

Abuse Allegations

HAVE YOU EVER BEEN FOUND GUILTY OF ABUSE, NEGLECT, OR EXPLOITATION? *

Yes
No

Other

DO YOU HAVE ANY FRIENDS OR RELATIVES WORKING FOR CCI, INC? *

Yes
No

If yes, state name(s) and relationship:

NAME AND RELATIONSHIP (FIRST)

NAME AND RELATIONSHIP (SECOND)

NAME AND RELATIONSHIP (THIRD)

References

list below three persons you are not related to, who have knowledge of your work performance within the last three years.

REFERENCE 1 – NAME

REFERENCE 1 – PHONE

REFERENCE 1 – NATURE OF RELATIONSHIP

REFERENCE 1 – YEARS AQUAINTED

REFERENCE 2 – NAME

REFERENCE 2 – PHONE

REFERENCE 2 – NATURE OF RELATIONSHIP

REFERENCE 2 – YEARS AQUAINTED

REFERENCE 3 – NAME

REFERENCE 3 – PHONE

REFERENCE 3 – YEARS AQUAINTED

REFERENCE 3 – NATURE OF RELATIONSHIP

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"You can steer yourself any direction you choose... You are the one who’ll decide where to go...

You’re off to Great Places! Today is your day! Your mountain is waiting, So...get on your way!"

-Dr. Seuss

Contact & Directions

Professional Plaza 102
129 NE 102nd Ave., Suite E
Portland, Oregon 97220
Phone: 503-594-1250
Fax: 503-594-1259
jenniferp@forcci.org

Donations

Send checks to:
CCI, Inc.
Attn: Donation
129 NE 102nd Ave., Ste. E
Portland, OR 97220
CCI thanks you for your thoughtful
donations of money, goods and services.

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