Telecommunication Specialist Preliminary Application

Name (Last, First, MI) (required)

Have you ever used another name? (required)

If Yes, list any assumed name, nickname, maiden, or another married name

Current Address (include city, state & zip) (required)

Telephone Number (required)

Email Address (required)

Have you ever applied or worked for the District before? (required)

If Yes, when

Have you ever been convicted of a crime? (required)

If Yes, Please provide detail

EDUCATION & TRAINING

Highschool Name (required)

City and State (required)

Year of Graduation (required)

Certification Received (required)

College Name

City and State

Degree or Number or Credits

Trade or Tech School Name

City and State

Certification, Diploma

Major Area of Study

EMPLOYMENT HISTORY

Current or Most Recent Employer (required)

Address (required)

Supervisor Name (required)

Contact Phone # (required)

Email Address (required)

Start Date (required)

End Date (required)

Position Held (required)

May we contact this employer? (required)

Duties (required)

Reason for Leaving (if still employed, why are you seeking other employment)? (required)

2nd Most Recent Employer Name:

Address

Supervisor Name

Contact Phone #

Email Address

Start Date

End Date

Position Held

May we contact this employer?

Duties

Reason for Leaving

THIS DISTRICT IS AN EQUAL OPPORTUNITY PROVIDER

Klamath 9-1-1 Communications District does not discriminate on the basis of race, color, national origin, sex, religion, age, or disability in employment. In compliance with the Americans with Disabilities Act, the District will provide reasonable accommodations to qualified individuals with disabilities. (required)

ACKNOWLEDGMENT

VETERANS' PREFERANCE (ORS 408.230)

Veterans who meet the minimum qualifications for a position open for recruitment may be eligible for preference in employment under Oregon law. If you are a Qualified Veteran or Qualified Disabled Veteran and would like to be granted preference in the selection and hiring process for a specific posted job, please fill out this Veterans' Preference Form and provide proof of eligibility by submitting a copy of form DD-214 or 215 (copy 4). This completed form and required supporting documentation must (required)

ACKNOWLEDGEMENT

CERTIFICATION & AGREEMENT

I certify all information given on this application and any supporting information is true and complete. I agree that if accepted for employment, I may be discharged if the District, at any time learns of any falsification or material omission in the information I have provided and if discovered prior to acceptance, I would be ineligible for consideration. I agree that, if accepted for employment, I will follow all District policies, rules, procedures, and all other directions. I understand that the District is committed to promoting safety and high professional standards of performance, productivity and reliability. In order to achieve this, all considered candidates must pass mandatory skills based tests and finalists may be subjected to a psychological testing, drug testing and physical testing prior to being hired to assure the applicant meets the mental stability and physical requirements and does not currently have narcotics, sedatives, stimulants, and other controlled substances in their body. I further understand that if I am selected as a finalist with the District, a thorough background investigation will be conducted. (required)

I CERTIFY

APPLICANT SIGNATURE: (required)

DATE: (required)

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