Community Access Services
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a nonprofit organization assisting persons with developmental disabilities in the community
1815 NW 169th Place, Suite 1060, Beaverton, Oregon 97006 (503) 533-4373 ~ FAX (503) 533-5833
EMPLOYMENT APPLICATION
Corporate Office Community Access Services 1815 NW 169th Place, Suite 1060 Beaverton, Oregon 97006 Phone: (503) 533-4373 Fax: (503) 533-5833 Equal Opportunity Employer Drug Free Workplace
Please circle the name of the program or locations you wish to be considered for work. A separate application must be submitted for each position and/or program you are applying for.
Madeline Group Home (01) Rockwood Group Home (02) St. Helens Group Home (03) 5405 SW 197th 1931 SE 157 th Drive 845 Matzen Street Aloha, Oregon 97006 Portland, Oregon 97233 St. Helens, Oregon 97051
Scappoose Group Home (04) Quincy Group Home (05) Spring Street Group Home (06) 33894 SE Oak Street 78791 Quincy Mayger Road 412 NE 5 th Street Scappoose, Oregon 97056 Clatskanie, Oregon 97016 Clatskanie, Oregon 97016
Stepping Stones (07) Oregon City Group Home (08) Aloha Group Home (10) Employment/ATE 1914 13 th Street 2018 SW 185 th 175 N. Nehalem Oregon City, Oregon 97045 Aloha, Oregon 97006 Clatskanie, Oregon 97016
St. Helens Employment/ATE (11) Supported Living Program (15) Orchard Group Home (18) 161 St Helens Street Beaverton, Oregon 236/238 Orchard Street St. Helens, Oregon 97051 Clatskanie, Oregon 97016
Clackamas ATE (13) CAS Main Office (30) Fremont Group Home (21) 16097 A SE McLoughlin Blvd 1815 NW 169th Pl. Ste 1060 3601 NE 141 st Milwaukie, OR 97267 Beaverton, Oregon 97006 Portland, Oregon 97230
In Home Supports (22) Sterling Court Group Home (19) Clackamas and Washington Counties 14682 SE Sterling Court Clackamas, Oregon 97015
Thank you for your interest in our agency. Please complete the following pages of this application to the best of your ability. A resume may be attached but does not replace any answers for requested information in this applic ation. If the information provided on your application does not clearly show that you meet the qualifications for the job or any section is left blank, your application will not be considered . Office Use Only :
Date Submitted: ______Follow-up Date: ______
Please Print Clearly Using Black Ink!!
Name: ______Date:______Last First Middle
Address:______Street Apt/Unit/Space City State Zip
Home Phone: ______Message Phone: ______
Have you ever applied to work for CAS in the past? Yes / No If yes, when? ______
Have you ever been employed by CAS in the past? Yes / No If yes, which program? ______
You must be Over the Age of 18 to apply for this position . Are you over 18 years of age? Yes ____ No _____
Are you a United States citizen or an alien lawfully authorized to work in the United States ? Yes ____ No _____ (Proof of your ability to lawfully work in the United States will be required if an offer of employment is extended)
What position or type of work are you applying for? ______
Do you have experience working with individuals with developmental disabilities: Yes ____ No _____
If yes, please explain: 19+ yrs experience in developmental disabilities, ranging from direct care to senior leadership
How did you hear about our agency and position? ______
I understand that, upon hire, I will be asked to disclose any personal relationships as well as any financial/business r elationships that may represent an actual or potential conflict of interest for a CAS employee. Yes___ No____
Availability/Preferred Shifts: Days____ Evenings____ Nights____ Weekdays____ Weekends____
# Hours Available to Work ______Full Time / Part Time / On-Call Starting Wage Desired $______
List all your education. In addition, please list any non-work related experience that relates to the position you a re applying for with us, including volunteer and personal experience.
School Name & Location Course of Study Circle Years Completed Diploma/Degree
High School 9 10 11 12
College/ 1 2 3 4 University
Business, Tech, 1 2 3 4 or Other School
Branch Assignment Years of Service Rank Military Service
(Additional relevant experience, skills, training, or certifications ) License Type Issuing Authority/State License Number Expiration Date
EMPLOYMENT: Please give accurate and complete information for all full-time, part-time, temporary, voluntary employment and/or work experience.
Are you currently employed? Yes____ No____All current and past employment will be verified. If you do not wish to have your current employer contacted, please provide a reason for this request.
The State of Oregon requires disclosure of substantiated abuse/neglect history. Have you ever been subject to an investigation into allegations of abuse/neglect which resulted in a substantiated finding? Yes____ No____ If yes, please provide date______(Disclosed abuse/neglect information will be verified by the Department of Human Services.)
Start with your present or most recent employer. Company Name: Phone Number:
Address: Employment Dates:
Program/Department: Job Title:
Supervisor: Reason For Leaving:
Duties:
Company Name: Phone Number:
Address: Employment Dates:
Program/Department: Job Title:
Supervisor: Reason For Leaving:
Duties:
Company Name: Phone Number:
Address: Employment Dates:
Program/Department: Job Title:
Supervisor: Reason For Leaving:
Duties:
(Include all additional employment history on the insert page attached to the application.)
Note any additional references in the spaces provided on the next page. Please make contact with all individuals whom you list as a reference and inform them that a representative of CAS may be contacting them to verify information which you have provided on this application. Letters of reference can be attached to your application and will need to be verified. Additional Professional References Name Day Time Phone Number Occupation/Relationship Years Known
(Please do not list personal reference such as family, friends, or others who are unable to speak to your qualifications to the job you are applying for) I understand that if hired any offer of employment is contingent upon my lawful eligibility to work in the United Sta tes. I understand that I will be required to provide proof of my identity and employment eligibility in accordance to federal law and failure to do so would result in my termination. Yes___ No____
I understand that if hired a criminal background check will be conducted. I understand that any offer of employment is contingent on the outcome of my background check and that my application may be rejected by the State of Orego n Department of Human Services Mental Health Division. Yes____ No____
I understand that Community Access Services is a Drug Free Workplace and that any offer of employment is conting ent on participating in and passing a pre-employment drug screen. Yes___ No____
I have read the job duties of the position I am applying for and have had an opportunity to ask necessary questions. Yes___ No____
I understand the above statements and I have been given an opportunity to ask questions regarding any part of this a pplication. Yes____ No____
Authorization, Agreement, and Acknowledgment
**I certify that the information provided in this application, any attached resume, and supplemental materials are tr ue and complete to the best of my knowledge. I authorize investigation of all statements contained in this applicatio n for employment as may be necessary in arriving at an employment decision. **I understand that false or misleading information given in my application, resume, supplemental materials or sub sequent interview(s) may result in denial or discharge of employment, regardless of how or when discovered. I also understand that I may be asked to furnish verification of any of the information contained in this application. **I understand and agree that if I am hired and accept a position, such employment is “at-will” and either I or repr esentatives of Community Access Services may terminate employment, with or without cause at any time. If hired, I agree to abide by all policies, rules, and regulations of this agency. I understand that Community Access Services h as the right to change wages, hours, and working conditions at its discretion.
______Signature Date
For Office Use Only :
Date of Hire:______Rate of Pay: $______Track 1 / Track 2
Hired By:______Date:______
Additional Employers/Work Experience: (Attach to back of application)
Company Name: Phone Number:
Address: Employment Dates:
Program/Department: Job Title:
Supervisor: Reason For Leaving:
Duties:
Company Name: Phone Number:
Address: Employment Dates:
Program/Department: Job Title:
Supervisor: Reason For Leaving:
Duties:
Company Name: Phone Number:
Address: Employment Dates:
Program/Department: Job Title:
Supervisor: Reason For Leaving:
Duties:
______Signature Date