Personal Information


Most Recent Education Information

Most Recent Work Experience



Additional Information

(Exclude those which may disclose your race, color, religion, age, or national origin.)

Applicant's Signature

Please read and understand this statement before signing your application:

The information I have provided in this Application for Employment is true, correct and complete. False, incomplete or misrepresented information of any kind, will be sufficient cause for my application to be rejected or, if discovered after I am employed, cause for immediate termination of my employment.

I authorize the employer to contact and obtain information about me from previous employers, educational institutions and "references" I provided, and any other party necessary to verify the accuracy of information I disclosed in this application, a related employment resume or a personal interview. To assist in the processing of my Application, I waive all rights and claims I may otherwise have against the employer or its representatives, for seeking, and using information to evaluate my employment request and all other persons, corporations or organizations who provide information for this purpose.

This application will expire in 30 days. After that date, unless otherwise notified, I understand that my status as an applicant will end. I may re-apply for employment at any time.

This application is not an employment agreement. If I accept an offer of employment

I understand the employer may terminate my employment at any time, with or without cause and without prior notice, unless required by law. I understand that no one, other than an executive officer of the employer, has authority to enter into any employment agreement with terms contrary to the foregoing and then only in writing signed by such officer.

Drug Screen Notice

While the use of marijuana is authorized under state laws, marijuana is illegal under federal law and therefore is considered an illegal and/or unauthorized controlled substance in policies of Oregon Urology Institute and Oregon SurgiCenter . Accordingly, having any detectable level of marijuana in your system when completing your pre-employment drug screen will be considered a failed test and make you ineligible to be hired.

Please enter your full, legal name.