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Return Application To: Administration Office 75A Diamond Valley Rd, Markleeville, CA 96120 (530) 694-2287 Last Name First Name Middle Name Mailing Address, Number Street City State Zip Code Telephone Number(s) Email Address: Are you under 18 years of age? Yes No If yes, can you provide a work permit? Yes No Have you previously been employed by the County of Alpine? If yes, please give dates of employment and position: Yes No Are you currently employed? Yes No If yes, may we contact your present employer? If hired, can you present evidence of US Citizenship or proof of your legal right to work in the US? Yes No Proof of citizenship or immigration status will be required upon employment Yes No On what date would you be available for work? Are you available to work: Full Time Part Time Weekends Temporary Do you possess a valid driver's license. Have you ever been discharged or requested to resign from a position? If Yes, please explain circumstances and list dates. Are you physically able to perform the essential requirements of the job for which you are applying, with or without reasonable accommodations? Yes No Yes No Yes No (An interactive process after offer of employment is used to determine any reasonable accommodation needed.) Are you requesting a reasonable accommodation per the Americans with disability/CA Fair Employee & Housing Acts? WE ARE AN EQUAL OPPORTUNITY EMPLOYER Yes No Position(s) Applied For Date of Application Alpine County Application For Employment COVID-19 Vaccine mandated as of 1/1/2022 ---PAGE BREAK--- Education High School Graduate Yes No High School Equivalency or GED Yes No High School Undergraduate College/University Graduate/Professional School Name and Location Years Completed 9 10 11 12 1 2 3 4 1 2 3 4 Diploma/Degree Describe Course of Study. Describe any specialized training, apprenticeship, skills and honors. Describe any Volunteer Activities. State any additional information that you feel may be helpful to us in considering your application. Indicate any foreign languages you can speak, read and/or write. Fluent Good Fair Speak: Read: Write: References 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. Give name, address and telephone number of three references who are not related to you and are not previous employers. 1. 2 3. ---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. 2. 3. 4. Special Skills and Qualifications Summarize special job-related skills and qualifications acquired from employment or other experience. Employer Dates Employed Duties / Tasks Performed From To Address Telephone Numbers(s) Job Title Supervisor Reason for Leaving Employer Dates Employed Duties / Tasks Performed From To Address Telephone Numbers(s) Job Title Supervisor Reason for Leaving Employer Dates Employed Duties / Tasks Performed From To Address Telephone Numbers(s) Job Title Supervisor Reason for Leaving Employer Dates Employed Duties / Tasks Performed From To Address Telephone Numbers(s) Job Title Supervisor Reason for Leaving ---PAGE BREAK--- Applicant's Statement I certify that answers given herein, as well as all attached documents 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. I hereby understand and acknowledge that, unless otherwise defined by applicable law or written agreement executed by both employer and employee, any employment relationship with this organization is governed solely by this organization’s personnel policies and procedures, as amended from time to time. I understand that false or misleading information given in this application, supporting materials, or interview(s) may disqualify me from further consideration and if employed may result in discharge or other disciplinary measures. I understand, also, that I am required to abide by all rules and regulations of Alpine County. This application must be completed to qualify for consideration. All applications who meet the minimum qualifications are not guaranteed advancement through any subsequent phase of the selection process. Alpine County reserves the right to determine the number of best qualified applicants that may continue in the process. The process may include, but is not limited to, one or more of the following: application review, competitive screening, written examination, performance examination and/ or oral examination as well as the probationary period. By signing below, I hereby authorize the County of Alpine to inquire, verify and obtain information and documentation related to my employment history and educational institutions, for the purpose of establishing my qualifications and professional work habits as it pertains to my application for employment. Furthermore, I authorize any institution or individual to release and disclose any employment related information and documentation to the County of Alpine for the purpose of establishing my qualifications and professional work habits. Such employment related information may include but it is not limited to employment dates, job duties, rehire eligibility, salary and opinions regarding work performance. I acknowledge my employment is contingent on the disclosed employment information and hereby release and hold harmless, the County of Alpine and any individual or institution who disclosed employment related information from any liability or damage that may result from furnishing such requested information. Signature of Applicant Date