Apply Now Step 1 of 5 20% Applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, sexual orientation, marital or veteran status, the presence of a non-job-related medical condition or handicap, or any other status protected by law.Positions Applied For* Location*Multnomah / Clackamas Counties Regional OfficeLinn / Benton Counties Regional OfficeLane County Regional OfficeJackson County Regional OfficeReferral Source Friend Relative Walk-In Agency Advertisement – e.g., Oregonian, craigslist, etc. Other Referral SourceName* First Middle Last Email* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Telephone*Have you submitted an application here before?*YesNoHave you ever been employed here before?*YesNoAre you employed now?*YesNoMay we contact your present employer?*YesNoAre you a United States citizen or an alien lawfully authorized to work in the United States?*YesNoOn what date are you available for work?* Are you on a lay-off and subject to recall?YesNoDo you have a valid driver’s license?*YesNoHave you ever been arrested, charged or convicted of an offense greater than a minor traffic offense?*(Conviction will not necessarily disqualify applicant from employment.)YesNoPlease ExplainAre there any criminal charges pending against you?*YesNoPlease ExplainHave you ever been investigated for child abuse/neglect or investigated for abuse/neglect in any Developmental Disability, Mental Health or Seniors program?*YesNoWere these charges substantiated/founded?YesNoPlease Explain Employment ExperienceStart with your present or last job. Include military service assignments and volunteer activities. Exclude organization names which indicate any status protected by law against discrimination. Indicate if you have no previous work history.Employer*Job Title*SupervisorTelephoneAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Dates EmployedFrom* To Hourly Rate/SalaryStartingFinalWork Performed*Reason For Leaving*EmployerJob TitleSupervisorTelephoneAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Dates EmployedFrom To Hourly Rate/SalaryStartingFinalWork PerformedReason For LeavingEmployerJob TitleSupervisorTelephoneAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Dates EmployedFrom To Hourly Rate/SalaryStartingFinalWork PerformedReason For Leaving Special Skills and QualificationsSummarize special skills and qualifications acquired from employment or other experienceAre you a veteran of the U.S. Military service?YesNoWhich Branch?Have you ever worked with developmentally disabled or mentally ill individuals?*YesNoplease identify type of program, location, and pertinent informationIndicate languages you can communicate in. (Please include sign language and Braille, as well as foreign languages.)LanguageUnderstandNoneFairGoodFluentSpeakNoneFairGoodFluentReadNoneFairGoodFluentWriteNoneFairGoodFluentLanguageUnderstandNoneFairGoodFluentSpeakNoneFairGoodFluentReadNoneFairGoodFluentWriteNoneFairGoodFluentLanguageUnderstandNoneFairGoodFluentSpeakNoneFairGoodFluentReadNoneFairGoodFluentWriteNoneFairGoodFluentList professional, trade, business or civic activities and offices held.(You may exclude those which indicate any status protected by law against discrimination.) List name, relationship, and telephone number of at least three references that you are not related to and not personal friends with that can speak about you professionallyName* First Last Relationship*Phone*Name* First Last Relationship*Phone*Name* First Last Relationship*Phone*Special Employment Notice to Disabled Veterans, Vietnam Era Veterans, and Individuals with Physical or Mental Disabilities Government contractors are subject to 38 USC 2012 of the Vietnam Era Veterans Readjustment Act of 1974, which requires that they take affirmative action to employ and advance in employment qualified disabled veterans and veterans of the Vietnam Era, and Section 503 of the Rehabilitation Act of 1973, as amended, which requires government contractors to take affirmative action to employ and advance in employment qualified disabled individuals. If you are a disabled veteran, or have a physical or mental disability, you are invited to volunteer this information. The purpose is to provide information regarding proper placement and appropriate accommodation to enable you to perform the job to the best of your ability in a proper and safe manner. This information will be treated as confidential. Failure to provide this information will not jeopardize or adversely affect your consideration for employment.If you wish to be identified, please sign below Disabled Individual Disabled Veteran Vietnam Era Veteran EduationHigh School*Years Completed9101112DiplomaYesNoDescribe Course of StudyDescribe specialized training, apprenticeship, skills and extra curricular activitiesHonors receivedCollege/UniversityYears Completed12345Degree(s)Describe Course of StudyDescribe specialized training, apprenticeship, skills and extra curricular activitiesHonors receivedGraduate/ProfessionalYears Completed1234Degree(s)Describe Course of StudyDescribe specialized training, apprenticeship, skills and extra curricular activitiesHonors received State any additional information you feel may be helpful to us in considering your applicationApplicant’s Statement I certify that answers given herein are true and complete to the best of my knowledge. I authorize ASI to investigate all statements contained in this application for employment and to contact any and all parties as may be necessary in arriving at an employment decision. I hereby release and hold harmless ASI, its representatives, and anyone contacted during this investigation process from liability for any possible resulting damages. I understand that this application is not – and is not intended to be – a contract of employment. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge, no matter when such information is discovered. I understand, also, that I am required to abide by all rules and regulations of the company.Write your first and last name to verify the above statement* First Last Date*
