Employment Application Form HR Date Recieved MM slash DD slash YYYY Completely fill out application and sign it. It is the applicant’s responsibility to ensure that the application is on file in Human Resources on the final filing date. Resumes are not acceptable in lieu of an application. Late applications will be rejected. Position Applying for:*Please Select OneSupervisor of Field Engineering and Planning – Open until FilledScience Advisor – Open until FilledPipe Fitter – 12/16The deadline for submitting an application for this opening has passed. The deadline for submitting an application for this opening has passed. The deadline for submitting an application for this opening has passed. Name* First Middle Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Email Address* Main Phone*Work PhoneCell Phone Completion of the following four questions are required only if the position for which you are applying requires the possession of a valid California’s Driver’s LicenseDL #DL ClassDL StateCaliforniaAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificDL Expiration Date MM slash DD slash YYYY Did you pass High School, pass the State High School Equivalency Exam, or do you possess a G.E.D. certificate?* Yes No Name of College or UniversityMajorDegree/CertificateUnits CompletedName of College or UniversityMajorDegree/CertificateUnits CompletedAre you now or have you ever been employed with the District?* No Yes What dates were you employed with the district? And what was your position with the district?Are you related by blood or marriage to any person(s) presently employed with the District?* No Yes Employee 1 NameRelationship to Employee 1Employee 2 NameRelationship to Employee 2Have you ever been discharged from employment or been forced to resign?* No Yes If yes, give detailsIf hired, can you provide proof of the legal right to work in United States?* Yes No Having read the job announcement which lists examples of job duties for the position, are you able to perform these duties with or without accommodation?* Yes No Have you ever worked under or been known by another name?* Yes No Alternative Name 1Dates you used this nameAlternative Name #2Dates you used this nameBilingual Skill: What language(s) do you fluently speak, read and write other than English?Do you qualify for credits based on U.S. Military Service?*If yes, submission of honorable wartime service, DD214 must be received with application. Yes No Please Read Carefully A resume is not acceptable in place of completing the following. Show your present or most recent job first. Show all employment during the past 10 years (or more, if qualifying Experience). Use a separate block for each Job Title (even those with same employer). Remember your acceptance depends on the completeness and accuracy of the information that is provided on this application. Important: To receive appropriate credit for work experience, date of employment must include month, day, and year. Special Licenses, Certificate, or Registration RequirementsFill in this section only if license(s) etc., are required for this job. Include title, date issued, date expires, serial number, and which state and/or agency issued it.Job TitleDescribe your duties fully:Reason for LeavingFrom Date MM slash DD slash YYYY To Date MM slash DD slash YYYY # of Hours worked weeklyOrganization Name and AddressSupervisor and Phone NumberMay we contact? Yes No Job TitleDescribe your duties fully:Reason for LeavingFrom Date MM slash DD slash YYYY To Date MM slash DD slash YYYY # of Hours worked weeklyOrganization Name and AddressSupervisor and Phone NumberMay we contact? Yes No Job TitleDescribe your duties fullyReason for LeavingJob From Date MM slash DD slash YYYY Job To Date MM slash DD slash YYYY # of Hours worked weeklyOrganization Name and AddressSupervisor and Phone NumberMay we contact? Yes No Job TitleDescribe your duties fullyReason for LeavingJob From Date MM slash DD slash YYYY Job To Date MM slash DD slash YYYY # of Hours worked weeklyOrganization Name and AddressSupervisor and Phone NumberMay we contact? Yes No Job TitleDescribe your duties fully:Job Reason for LeavingJob From Date MM slash DD slash YYYY Job To Date MM slash DD slash YYYY # of Hours worked weeklyOrganization Name and AddressSupervisor and Phone NumberMay we contact? Yes No Please identify and explain all periods of unemployment in excess of one month during the past 10 years: ReasonFrom Date MM slash DD slash YYYY To Date MM slash DD slash YYYY ReasonFrom Date MM slash DD slash YYYY To Date MM slash DD slash YYYY ReasonFrom Date MM slash DD slash YYYY To Date MM slash DD slash YYYY Signature*Date* MM slash DD slash YYYY The following information is requested to assist in implementing the District’s Affirmative Action and Equal Employment Opportunity policy and state and federal requirements. Submission of this information is strictly voluntary and will NOT be retained with your application but handled separately and confidentially for statistical purposes. How did you learn of this job opening? Newspaper Ad Internet Trade Publication WWD Job Interest Card WWD Employee Other Name of Newspaper Publication:Name of SiteName of Trade PublicationPlease describeGender Female Male Age Under 40 40 or over Accommodations Needed I can perform the essential functions of the position WITHOUT reasonable accommodations. I can perform the essential functions of the position WITH reasonable accommodations. Please describe the type of assistance or accommodations needed: Disability: A person with a disability is an individual who:(1) has a physical or mental impairment or medical condition that limits one or more life activities, such as walking, speaking, breathing, performing manual tasks, seeing, hearing, learning, caring for oneself or working; (2) has a record or history of such impairment or medical condition; or (3) is regarded as having such an impairment or medical condition.I have a disability I have a disability which meets the definition above Ethnic Affiliation White – All persons having origins in any of the original peoples of Europe, the Middle East, or North Africa. Black or African American – All persons having origins in any of the black racial groups of Africa. Hispanic – All persons of Cuban, Mexican, Puerto Rican, Central or South American, or other Spanish culture, or origin, regardless of race. Not Hispanic or Latino Native Hawaiian or Other Pacific Islander – All Persons having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. Asian – All persons having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, or Vietnam. American Indian or Alaskan Native – All Persons having origins in any of the original peoples of North or South America (including Central America), and who maintains tribal affiliation or community attachment. Δ
