Office use only:

     Received by ___________________   Date ______________

                                                                                                                                                                    

 

      

 

 

16432 SE Stark StreetPortland, OR 97233-3960               503-232-0394                                              www.rainbowadulatliving.org

 

Our Mission

 

The mission of Rainbow Adult Living Facilities, Inc. is to support quality lifestyles for adults with developmental disabilities.  The agency recognizes that persons with disabilities have a right to the same opportunities for fulfillment in their lives as persons without disabilities.  These include the opportunity to increase one’s independence, the opportunity to be productive, and the opportunity to be fully integrated into one’s community.

 

EMPLOYMENT APPLICATION

 

RAL is an equal opportunity employer and all qualified applicants, including disabled veterans and veterans of the Vietnam Era, will be considered for employment without regard to race, color, religion, natural origin, physical or mental handicap, sex or age.  Any applicant may notify the Equal Employment Opportunity Commission or any other appropriate agency if they believe they have been discriminated against.

 

PERSONAL DATA:                                       Social Security Number: ___________________________________________

 

Name:  _____________________________________, ___________________________________________, _______

                                                         Last                                                                                                                       First                                                             Middle Initial

Please list any previous names: ______________________________________________________________________

 

Address: ______________________________________________, ____________________________, ___________

                                                               Street Name                                                                                                       City, State                                         Zip Code

 

Phone: ________________________ Email address: ____________________________________________________

 

Do you hold a valid driver’s license? ___ No ___Yes ______________________________________________________

                                                                                                                                                            State and License Number

Do you have transportation to work? ___Yes___No

 

Are you a citizen of the United States? ___Yes___No    If no, what is your visa status? ____________________________________________

 

Have you ever been the subject of a protective service investigation in which abuse has been substantiated against you?  ___No___Yes If yes, please explain: _________________________________________________________________

______________________________________________________________________________________________

 

MILITARY SERVICE RECORD:

Branch: ____________________________ Date Entered: ______________ Date Discharged: ___________________

Nature of Duties: ________________________________________________________________________________

Service Schools (course, titles, and dates): _____________________________________________________________

______________________________________________________________________________________________

 

EDUCATION AND TRAINING:

Circle the highest grade completed:  High School: 1234  College: 12345678

List High School(s) attended, including locations and date(s):

                                          Name                                                                                          Location                                                                       Dates Attended

1.  ____________________________________________________________________________________________

2.  ____________________________________________________________________________________________

 

 

List Colleges attended, including locations and date(s):

                                          Name                                                                                            Location                                                                      Dates Attended

1.  _____________________________________________________________________________________________

2.  ____________________________________________________________________________________________

3.  ____________________________________________________________________________________________

Major fields of study: ______________________________________________________________________________

Degree(s) held and dates achieved: __________________________________________________________________

______________________________________________________________________________________________

Additional professional courses, seminars, or trainings you have attended (please include dates and describe training, any special skills acquired or equipment you can operate):

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

 

EMPLOYMENT HISTORY: (List most recent employment first.  Include summer or temporary jobs. Be sure all your experience or employers related to this job are listed here, in the summary following this section or on an extra sheet of paper if necessary.)

 

Company: ______________________________________________________ Phone: ________________________

Address: ____________________________________________________ Supervisor: ________________________

Job Title: ______________________________________________________ Wage or Salary: ___________________

                                                                                                                                                                                                                           $Started                  $Last

Responsibilities: _________________________________________________________________________________

______________________________________________________________________________________________

Employed from: ___________ to ___________. Reason for leaving: _________________________________________

May we contact your previous supervisor for a reference? ___Yes___No

 

Company: _________________________________________________________ Phone: _______________________

Address: _______________________________________________________ Supervisor: _______________________

Job Title: _______________________________________________________ Wage or Salary: ___________________

                                                                                                                                                                                                                              $Started                  $Last

Responsibilities: __________________________________________________________________________________

______________________________________________________________________________________________

Employed from: ___________ to ___________. Reason for leaving: _________________________________________

May we contact your previous supervisor for a reference? ___Yes___No

 

Company: _________________________________________________________ Phone: _______________________

Address: _______________________________________________________ Supervisor: _______________________

Job Title: ________________________________________________________ Wage or Salary: __________________

                                                                                                                                                                                                                             $Started                  $Last

Responsibilities: __________________________________________________________________________________

______________________________________________________________________________________________

Employed from: ___________ to ___________. Reason for leaving: _________________________________________

May we contact your previous supervisor for a reference? ___Yes___No

 

 

 

Summarize other employment related to this job:

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

 

Please list periods of unemployment during the past five years:

1.  From: _________ to _________ Reason: _______­­­­­_____________________________________________________

2.  From: _________ to _________ Reason: ____________________________________________________________

3.  From: _________ to _________ Reason: ____________________________________________________________

 

 

PERSONAL REFERENCES (Please do not include relatives or former employers):

          Name                                                       Address                                                           Phone                             Relationship                 Known how long?

 

1.    ________________________________________________________________________________________

2.    ________________________________________________________________________________________

3.    ________________________________________________________________________________________

4.    ________________________________________________________________________________________

 

PERSONAL OR CAREER GOALS AND EXPECTATIONS:

 

Please indicate the position you are applying for: ________________________________________________________

What are your long-range goals or objectives? __________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

Please list your hobbies, volunteer work or other information that would explain your qualities: ______________________________________________________________________________________________

______________________________________________________________________________________________

Are you available for employment immediately? ___Yes ___No

 

Please list any time you would not be available for work: ___________________________________________________

 

 

The statements and information herein have been reviewed by me and are to the best of my knowledge true and complete.  I understand that giving false information or misrepresentation may be grounds for denial of employment or discharge if hired.  I authorize Rainbow Adult Living to verify my past and present employment and check my business and personal references.  

                                                                               

 

______________________________________________________________________________________________

Signature of Applicant                                                                                                                                                                    Date