Return completed applications to our Office at 233 SW 2nd Street Corvallis, OR 97333 or FAX to 541-752-9631
Name________________________________________________ Date of Birth______________ □ Over 25
Address_____________________________________________________________ City______________________________
I would like to work _____ Full Time _____ Part Time Approximate Hours Available _______________________
Phone_____________________ Do you have voice mail? _______ Social Security # ________-______-________
E-mail________________________________________________ Are you a US Citizen? _______________
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) _________________________________________________________________________________
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? ____________________________________
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? ______________________________________________________
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:__________________________________
___________________________________________________________________________________________________
Have you ever been convicted of any felony crime? _______ When? ____________________ What? __________________
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? __________________________________
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)