Employment Application NORTH MORROW VECTOR CONTROL DISTRICT EMPLOYMENT APPLICATION - SEASONAL POSITION Last Name (required) First Name (required) M.I. Date (required) Street Address (required) Apartment / Unit # City (required) State (required) Zip (required) Phone (required) E-mail Address (required) Driver's License # (required) Position Applied For (required)Vector Surveillance Technicians Internship Are you a citizens of the United States? If no, are you authorized to work in the U.S.? (required) Yes No Are you 18 Years of age or older? (required) Yes No EDUCATION High School Address/City From To Granduate? Yes No Degree/Certificate College/University Address/City From To Graduate? Yes No Degree/Certificate Vocational/Other Training Address/City From To Graduate? Yes No Degree/Certificate PREVIOUS EMPLOYMENT List most recent employer first. Employer 1 - Most Recent Company/Employer (required) Phone (required) Supervisor (required) Address (required) Job Title (required) Dates of Employment (required) Reason for Leaving (required) Responsibilities (required) May we contact this supervisor for a reference? Yes No Employer 2 Company/Employer Phone Supervisor Address Job Title Dates of Employment Reason for Leaving Responsibilities May we contact this supervisor for a reference? Yes No Employer 3 Company/Employer Phone Supervisor Address Job Title Dates of Employment Reason for Leaving Responsibilities May we contact this supervisor for a reference? Yes No MILITARY SERVICE (if applicable) Branch From To Rank at Discharge Type of Discharge If other than honorable, explain PROFESSIONAL REFERENCES Please provide three professional references (not family members). Reference 1 Full Name Relationship Company Phone Address Reference 2 Full Name Relationship Company Phone Address Reference 3 Full Name Relationship Company Phone Address POSITION - SPECIFIC QUESTIONS 1. Seasonal Availability Earliest Start Date Latest End Date (if applicable) Pre-planned absences June-September? (list dates or leave blank if none): 2. Certifications & Licensing Are you willing to study for and pass the two state exams for your Oregon Public Health Pesticide Applicator's License? (Training materials provided.) Yes No Do you have a valid Driver's License? Yes No Is your driving record clear of major infractions for the past 3 years? Yes No 3. Physical & Environmental Readiness Are you comfortable working outdoors for 10-hour shifts in variable conditions (heat, mud ,thick vegetation, intects/ticks)? Yes No Are you able to routinely lift 30 lbs and occasionally lift up to 50 lbs? Yes No Safety is our top priority. Are you willing to wear all required PPE (safety glasses, helmets, masks) as the task requires? Yes No 4. Logistics & Skills Do you have reliable transportation to and from the District Office? Yes No Do you have a personal cell phone for field communication? Yes No Technical Experience - Check all that apply: Operating ATVs/Off-road vehicles Backing up/ maneuvering small trailers Operating a manual transmission Basic mechanical skills (changing tires, oil, etc.) Previous experience with hand-spray or power spray equipment 5. Professional Interest We invest significantly in your training. If successful this year, would you be interested in returning for future seasons? Yes No Unsure I certify that all information provided in this application is true, accurate, and complete to the best of my knowledge. I understand that any false, misleading, or omitted information may result in disqualification from consideration or, if discovered after hire, may result in termination of employment. I authorize the North Morrow Vector Control District to verify all information provided and to contact the references listed. Signature Date Thank you for your interest in the North Morrow Vector Control District. We will review your application and contact you as soon as possible. There was a problem saving your submission. Please try again later. Please wait while your submission is being saved... Submitting...Submit Thank you, your submission has been received.