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Alpine County Return Application To: Administration Office Application P.O. Box 387 Markleeville, CA 96120 For Employment (530) 694-2287 Alpine County will consider applicants for all positions without regard to race, color, religion, sex, national origin, age, marital or veteran Status, the presence of a non-job-related medical condition or handicap, or any other legally protected status. Providing the information requested on this application is voluntary, however, omission of any item may result in your qualifications not receiving full consideration. (PLEASE PRINT) Position(s) Applied For Date of Application Middle Name Last Name First Name State Street Mailing Address, Number Zip Code City Telephone Number(s) Social Security Number (voluntary) If you are under 18 years of age, can you provide required No proof of your eligibility to work? Yes Yes Have you ever been employed with us before? No If yes, give date: No Are you currently employed? Yes Yes No May we contact your present employer? Are you prevented from lawfully becoming employed in this country Yes because of Visa or Immigration Status? No Weekends Temporary Full Time Are you available to work: Part Time Do You possess a valid driver's license # No Yes No Yes Have you ever had any job-related training in the United States military? If Yes, please describe. Are you physically or otherwise able to perform the duties of the job for which Yes No you are applying? Yes No Have you been convicted of a crime within the last 7 years? Conviction will not necessarily disqualify an applicant from employment. (Do not include juvenile record or minor traffic violations.) If yes, please explain. Have you ever been discharged, rejected during probation, Yes No or resigned under pressure? WE ARE AN EQUAL OPPORTUNITY EMPLOYER Proof of citizenship or immigration status will be required upon employment On what date would you be available for work? ---PAGE BREAK--- Education High School Graduate Yes No High School Equivalency or GED Yes References Give name, address and telephone number of three references who are not related to you and are not previous employers. 1. 2. 3. No High School Undergraduate College/University Graduate/Professional Diploma/Degree Describe Course of Study. Describe any Volunteer Activities. State any additional information that you feel may be helpful to us in considering your application. Fluent Good Fair Speak: Read: Write: School Name and Location Years Completed Describe any specialized training, apprenticeship, skills and honors. Indicate any foreign languages you can speak, read and/or write. List professional, trade, business or civic activities and offices held. You may exclude memberships which would reveal sex, religion, national origin, age, ancestry or handicap or other protected status. 9 1 10 11 12 2 3 4 1 2 3 4 ---PAGE BREAK--- Employment Experience Start with your present or last job. Include any job-related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin, handicap or other protected status. Do not attach resume in lieu of completing this section. 1. Employer Dates Employed To Duties / Tasks Performed From Address Telephone Numbers(s) Hourly Rate /Salary Starting Final Job Title Supervisor Reason for Leaving Special Skills and Qualifications Summarize special job-related skills and qualifications acquired from employment or other experience. 2. Employer Dates Employed To Duties / Tasks Performed From Address Telephone Numbers(s) Hourly Rate /Salary Starting Final Job Title Supervisor Reason for Leaving 3. Employer Dates Employed To Duties / Tasks Performed From Address Telephone Numbers(s) Hourly Rate /Salary Starting Final Job Title Supervisor Reason for Leaving 4. Employer Dates Employed To Duties / Tasks Performed From Address Telephone Numbers(s) Hourly Rate /Salary Starting Final Job Title Supervisor Reason for Leaving ---PAGE BREAK--- Applicant's Statement I certify under penalty of perjury under the laws of the State of California that answers given herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision and authorize access to all criminal, driving and medical records necessary for such investigation. This application for employment shall be considered active for a period of time not to exceed 180 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time. I hereby understand and acknowledge that specified employment relationships with this county are of an ''at will'' nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this “at will” employment relationship may not be changed by any written document unless such change is specifically acknowledged in writing by an authorized executive of this organization. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in elimination from the examination process or forfeiture of all employment rights. I understand, also, that I am required to abide by all rules and regulations of the employer, that a memorandum of understanding has been entered into between Alpine County employees and Alpine County which is the contract which defines the terms and conditions of employment, and that employment appointment will be conditional upon a satisfactory pre-employment medical evaluation. Date Signature of Applicant FOR PERSONNEL DEPARTMENT USE ONLY No Arrange Interview Yes Remarks Date of Employment Yes No Employed Department Hourly Rate / Salary Job Title By Date Name and Title NOTES