BLACKLEDGE FURNITURE                             WAREHOUSE – DELIVERY EMPLOYMENT APPLICATION

     Return completed applications to our Office at   233 SW 2nd Street Corvallis, OR 97333  or  FAX  to  541-752-9631

Name________________________________________________    Date of Birth______________   or  □ Over 25

Address_____________________________________________________________ City______________________________

  I would like to work        _____ Full Time    _____ Part Time     Approximate Hours Available _______________________

Phone___________________________    Do you have voice mail? _______

E-mail________________________________________________       Are you a US Citizen?  _______________

PRIOR EMPLOYMENT HISTORY:

Your Last Employer ___________________________________________________       Ph.___________________________

Duties? _______________________________________________________________________________________________

Salary $__________       per_______                   Date Started ______________                Date Ended________________

Reason for Leaving? ____________________________________________________________________________________

What did you like most about the job? _____________________________________________________________________

What did you dislike about the job? ________________________________________________________________________

Contact          (name) ____________________________________________________________________________________

                       (address) _________________________________________________________________________________

OTHER PRIOR EMPLOYMENT:

Employer ___________________________________________________________       Ph.___________________________

Duties? _______________________________________________________________________________________________

Salary $__________       per_______                   Date Started? _______________      Date Ended? ________________

Reason for Leaving? ____________________________________________________________________________________

What did you like most about the job? _____________________________________________________________________

What did you dislike about the job? ________________________________________________________________________

Contact          (name) ____________________________________________________________________________________

                       (address) _________________________________________________________________________________

Have you been security bonded in a prior Job? _______     Are you bondable? ____________________________________

PHYSICAL:

Height _____ft. _____in.            Weight ______lbs.                  Date of last Physical Exam? __________________           

Are you comfortable safely lifting and carrying bulky 50-70 lb items? ____________________________________________

______________________________________________________________________________________________________

Are you used to carrying bulky, heavy, 50-70 pound loads?______    Do you smoke? _____    Any Color Blindness? _____

Can you work most Saturdays? _______    Can you work most Sundays? (12:00-5:00)? _______

Do you participate in any sports?_____              Which sports?_________________________________________________

Do you exercise regularly?____________  What forms? ______________________________________________________

DRIVING:

Drivers License No.________________________             State_________             Restrictions? ______________________

How many traffic citations (other than parking) have you had in the last five years?_________________________________

Please list dates & details ____________________________________________________________________________

Have you been involved in any traffic accidents in the last five years? ___________________________________________

If yes, explain:__________________________________________________________________________________________

*We check all driving records against the state DMV records. For delivery staff the ability to meet our insurance  company’s approval standards is an important part of our job requirements. If you have had violations which are not listed above, and can not meet our insurance company standards for drivers, your wage level will normally be reduced, regardless of prior wage offers.

Have you driven medium or large size trucks?________________ If yes, explain:__________________________________

___________________________________________________________________________________________________

OTHER SKILLS:

Have you done any woodworking? _______ If yes, explain: ____________________________________________________

_____________________________________________________________________________________________________

Have you built or repaired furniture? _______ If yes, explain: ___________________________________________________

______________________________________________________________________________________________________

Have you done upholstery work?__________________________________________________________________________

Have you done painting or building maintenance?____________________________________________________________

How good are you at minor automotive repairs? _____________________________________________________________

How well do you solve problems?  _____ Excellent   _____ Good   _____ Average   _____ Fair   _____ Poor

How well do you communicate with supervisors when you encounter a problem? __________________________________

PERSONAL:

What was the last year of schooling you completed? _____________ GPA __________ Major________________________

What are your long term career interests? __________________________________________________________________

How long have you lived in the Corvallis-Albany area?__________________________________________________________

Military Service?________________________________________________________________________________________

What are your hobbies? __________________________________________________________________________________

Why do you think you would like working for us as a warehouse/delivery person_________________________________________________________________________________________________

How did you hear about our employment opportunity?

___ Just came in to inquire                            ___ Oregon State Employment Department Referral

___ Corvallis Gazette Times Newspaper Ad    ___ Albany Democrat Herald Newspaper Ad

______________________________________________________________________________________________________

What level of compensation do you desire per hour? $________

IMPORTANT INFORMATION

I authorize and request Blackledge Furniture or their agents, or insurers, to contact my previous employers for information about my job performance, and authorize other reporting agencies including Division of Motor Vehicles, credit reporting agencies, Education institutions and Law Enforcement agencies to provide information they may have about me to Blackledge Furniture. If selected as a finalist or hired for a position, I agree to undergo a physical examination including a drug abuse screening at Blackledge Furniture’s expense and authorize release of my medical history by any physicians who have treated me in the past five years. I certify that the information given on this application is true, and I agree that if information I have listed is later found to be untrue, I may be terminated for cause.

Blackledge Furniture is an Equal Opportunity Employer.

_____________________________________________________________             __________________________________

(signature)                                                                                                         (date)