Zip O Log Mills

Zip-O-Log Mills, Inc.
P.O. Box 2130
Eugene, OR 97402 EMPLOYMENT APPLICATION

Position Applied For:	Date of Application:
First Name:	MI:	Last Name:
Street:	City:	State:	Zip Code:
Phone:	Message Phone:
Are you legally eligible to work in the U.S.? Yes No
Driver's License Number:	State Issued:	Email:
Have you ever worked in this facility? Yes, Date: No
Do you have relatives working at this facility? Yes No		Name:
On what date would you be available for work?
Where did you hear about this position?	Newspaper	Referred By	Other

Education	City, State	Years Attended	List Diploma or Degree
High School:
College:
College:
Trade/Technical:
Other:
Please describe specialized training or skills that you have that are relevant to this position:

An Equal Opportunity Employer

We are an equal opportunity employer. We do not discriminate on the basis of race, color, religion, national origin, sex, age, marital status, or existence of any physical or mental disability that does not interfere with the performance of the position for which you are applying, Information provided on the application will not be used for any discriminatory purpose.

EMPLOYMENT EXPERIENCE

Most recent employer Are you presently working for this employer? Yes No If yes, may we contact? Yes No
Company:	Type of Business:
Address:	Phone:
Your Title:	Employed From:	To:
Supervisor:	Starting Salary:	Ending Salary:
Job Duties:
Reason for Leaving:

Company:	Type of Business:
Address:	Phone:
Your Title:	Employed From:	To:
Supervisor:	Starting Salary:	Ending Salary:
Job Duties:
Reason for Leaving:

Company:	Type of Business:
Address:	Phone:
Your Title:	Employed From:	To:
Supervisor:	Starting Salary:	Ending Salary:
Job Duties:
Reason for Leaving:

Company:	Type of Business:
Address:	Phone:
Your Title:	Employed From:	To:
Supervisor:	Starting Salary:	Ending Salary:
Job Duties:
Reason for Leaving:

JOB RELATED BACKGROUND

1. Are you physically able to perform this job safely and without a significant risk of substantial harm to yourself or others?
Yes No
Note you may answer YES to questions 1 above if you can perform all essential functions of the job with or without reasonable accommodations. The Company will provide reasonable accommodation to a person with a disability. However, you are still not required to identify yourself as a disabled person on this application form. If you can perform the essential tasks of the job only with an accommodation then please respond to the following question: How would you perform the tasks, and with what accomodation(s)?

2. Please describe your SAFETY RECORD over the past three years. Please include in this description any accidents or “near misses” you have had during the past year.

3. Zip-O-Log Mills, Inc., has a goal to achieve the highest possible attendance from our employees. Please describe your ATTENDANCE RECORD over the past three years. Please include in this description how many days off from work you had, for any reason, during the last year.

4. Do you ever take any illegal drugs (such as (but not limited to) marijuana, cocaine)? Yes No

5. Have you taken any illegal drug in the last year? Yes No

6. Have you ever been convicted of a felony or agreed to a court settlement for a lesser crime after having been charged with a felony? Yes No
IF Yes please explain:

(Note: “YES” answers to the above questions may not necessarily bar you from employment here)

REFERENCES
Please list three references. Include only individuals familiar with your work ability. Do not include relatives.

Name	Address	Phone	Relationship/Years known

AGREEMENT & RELEASE

By signing this application I declare that the information provided by me is complete and true to the best of my knowledge. I understand that any misrepresentation or omission on this application may preclude an offer of employment or may result in a withdrawal of an employment offer or may result in my discharge from employment if I am already employed at the time the misrepresentation or omission is discovered.

In the event I undergo a medical examination or evaluation as part of the job placement process, I agree to supply only information which is true to the best of my knowledge and I authorize the physician or his/her representative to provide any information or opinion, as it relates to my employment, to the Company regarding this examination or evaluation, I understand that if the Company determines that I have made any false oral or written statements or answers or any misreprentation or any omission of significant information to the Company or to the physician or to his/her representative, the Company is entitled to terminate my conditional or actual employment at any time.

I authorize this company or its agents to verify any information on this applicaion including, but not limited to references, criminal history and motor vehicle driving records. I authorize all persons, schools, companies, and law enforcement agencies to release any information concerning my background, and release any said persons, schools, companies, or agencies from any liability for issuing this information.

Zip-O-Log Mills, Inc., supports a drug and alcohol free working environment. Employees are expected to be in a suitable mental and physical condition to perfrom their jobs. I am willing to submit to drug/alcohol testing to detect the use of illegal drugs and/or alcohol prior to and during employment.

I understand that employment at Zip-O-Log Mills, Inc., is on an “at will” (that is, mutual consent) basis. Therefore I agree that either I or the Company has the proper right to terminate my employment with or without cause at any time, so long as there is no violation of applicable state or federal laws.

Signature: Date:

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