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PLEASE TYPE OR PRINT DATE RECEIVED For Official Use Only Accepted Initials Rejected Ed License/Cert Exp Incomplete Other EMPLOYMENT APPLICATION AN EQUAL OPPORTUNITY EMPLOYER Human Resources Division 10890 San Pablo Avenue El Cerrito, CA 94530 www.el-cerrito.org POSITION APPLYING FOR: Print Exact Title From Job Announcement 1. Social Security Number (Use of your Social Security Number is voluntary and will be used for identification purposes only.) 2. Last Name First Name Middle Name 3. Address: No. Street Apt No. City State/Zip Code 4. Phone: Home Work/Message Cell 5. Email Address: 6. Driver’s License: State Number Expiration Date 7. Have you ever been rejected during probation, discharged, or forced to resign from any employment within the last ten years? If yes, give name and address of the employer(s), reason for release and the dates of employment. If your answer is yes, it is not necessarily a bar to employment. Each case is given individual consideration based on job relatedness. 9. Are you fluent in any language other than English? If so, please 10. Have you previously been employed by the City? Yes No If yes, when? 8. Are you related to any City employee? Yes No Name of Relationship: Yes No 11. EDUCATION: Check the appropriate box if you possess the following: High School Diploma G.E.D. Certificate California High School Proficiency Certificate Level of Education Achieved Names of Colleges/Universities Course of Study/ Major Units Completed Sem Qtr Degree Type Date Awarded 12.Licenses, Certificates or Registration required for this job Title Issue Date Expiration Date Number ---PAGE BREAK--- 13. EMPLOYMENT HISTORY—The following section must be filled out completely. List experience that relates to the qualifications as required on the job announcement. Begin with your most recent experience. List each promotion separately. Use additional sheets if necessary. Voluntary non-paid experience will be accepted if job related. A resumé or other supporting documentation may be attached but it may not be used as a substitute for completing this section. Job Title Job Duties From To Mo/Yr Mo/Yr Yrs Mo Hrs Per Mo. Salary Reason for Leaving Volunteer Work Employer’s Name and Address Supervisor’s Name and Phone 14. I will accept the following employment type with the City: Full-time Part-time Temporary Seasonal 15. How did you hear about this position? City Website City Employee Other Agency Other Employer’s Name and Address Supervisor’s Name and Phone Employer’s Name and Address Supervisor’s Name and Phone Employer’s Name and Address Supervisor’s Name and Phone Employer’s Name and Address Supervisor’s Name and Phone 17. I CERTIFY that the statements made by me in this application are true, complete, and correct to the best of my knowledge and belief, and are made in good faith. I understand and agree that misstatements/omissions of material fact will cause forfeiture of my rights to employment with the City of El Cerrito. Date Signature 16. May we contact your present employer? Yes No From To Mo/Yr Mo/Yr Yrs Mo Hrs Per Mo. Salary Reason for Leaving Volunteer Work From To Mo/Yr Mo/Yr Yrs Mo Hrs Per Mo. Salary Reason for Leaving Volunteer Work From To Mo/Yr Mo/Yr Yrs Mo Hrs Per Mo. Salary Reason for Leaving Volunteer Work From To Mo/Yr Mo/Yr Yrs Mo Hrs Per Mo. Salary Reason for Leaving Volunteer Work Job Title Job Duties Job Title Job Duties Job Title Job Duties Job Title Job Duties ---PAGE BREAK--- The City of El Cerrito is an Equal Opportunity Employer. It is the policy of the City of El Cerrito that all employment decisions and person- nel policies will be applied equally to all City employees and applicants and be based upon the needs of City service, job related merit, and ability to perform the job. CITY OF EL CERRITO VOLUNTARY E.E.O.C. QUESTIONNAIRE: The Federal Equal Employment Opportunity Commission (EEOC) requires each state and local government to file a report summarizing the racial/ethnic makeup of its workforce. This survey gives the City information to assist the City in measuring Equal Employment Opportunity progress. This questionnaire is a supplemental form that is not connected to the application, is stored in a separate file, and is voluntary. RACE/ETHNIC BACKGROUND: Please check ONE box as to the race or ethnic background with which you identify: APPLICANTS WITH DISABILITIES: Qualified individuals with a disability, who are able to perform the essential functions of the job, with or without reasonable accommodation, and need special testing arrangements, must contact the City of El Cerrito Human Resources Division at (510) 215-4315. Please attach this sheet as the very last page of your application package, behind any resumés, letters or other attachments. NAME POSITION APPLYING FOR DATE OF BIRTH GENDER MALE FEMALE White or Caucasian, non-Hispanic Black or African American, non-Hispanic Hispanic or Latino (of any race): Mexican, Puerto Rican, Cuban, Other Hispanic or Latino [Dominican (Dominican Republic), Central Amer- ican (Costa Rican, Guatemalan, Honduran, Nicaraguan, Panamanian, Salvadoran), South American (Argentinean, Bolivian, Chilean, Colom- bian, Ecuadorian, Paraguayan, Peruvian, Uruguayan, Venezuelan), Spaniard] Asian: Asian Indian, Bangladeshi, Cambodian, Chinese, Hmong, Indonesian, Japanese, Korean alone, Laotian alone, Malaysian alone, Pakistani alone, Sri Lankan, Thai, Vietnamese, Other specified Asian. Filipino: All Filipino ancestry or origin. Native Hawaiian and Other Pacific Islander: Polynesian (Native Hawaiian, Samoan, Tongan), Micronesian (Guamanian or Chamorro), Melanesian (Fijian), Other specified Pacific Islander. Native American , American Indian or Alaskan Native Tribes: Persons having origins in any of the original peoples of North America, and who maintain cultural identification through tribal affiliation or community recognition. Two or More Races: According to defined ethnic background races as listed in definitions above.