employment application form california.pdf

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Desktop employer Applicant Duties Salary Reason FILLMORE Desktop employer Job Title Mo Mo Yr Duties Mo Yr Mo Settings stevem FILLMORE stevem FILLMORE Desktop Title Mo Yr Yr Duties Salary Yr Mo Yr Address CITY State
C:\Documents and Settings\stevem.FILLMORE\Desktop\employment application.01.2008.doc 
 
 
 
 
APPLICATION FOR EMPLOYMENT 
 
CITY OF FILLMORE, CALIFORNIA 
 
 
 
 
 
NAME _______________________________________________________ 
 
POSITION APPLIED FOR________________________________________ 
 
DATE ________________________________________________________ 
 
Please answer all questions correctly and accurately. All statements in your application are subject to 
verification. An incorrect statement may bar or remove you from employment.  Applications may be filed at 
Fillmore City Hall, or may be mailed to the ADMINISTRATIVE SERVICES MANAGER at: 
 
                                                            CITY OF FILLMORE 
                                                          250 CENTRAL AVENUE 
                                                           FILLMORE, CA 93015 
 
 
C:\Documents and Settings\stevem.FILLMORE\Desktop\employment application.01.2008.doc 
PERSONAL INFORMATION 
 
________________________________________________________________________________  
Last Name 
First 
Initial 
Position Applied for 
 
________________________________________________________________________________________ 
Mailing Address 
City 
State 
Zip 
 
_________________________ 
________________________ 
__________________________ 
Home Telephone 
Mobile or Work Telephone 
Social Security Number 
 
The age Discrimination in Employment Act of 1967 prohibits discrimination on the basis of age with 
respect to individuals who are at least 40 but less than 70 years of age. 
Are you at least 18 years of age?   
 
  
 
 
 
 
□YES □NO 
If selected, can you provide proof of your legal eligibility to work in the United States?      
□YES □NO 
Do you know anyone in our employ? 
 
 
 
 
□YES □NO 
 
Name: ___________________________________________ Dept: ________________________ 
 
Name: ___________________________________________ Dept: ________________________ 
 
Have you ever been convicted of a crime in the last 7 years?  
 
 
 
□YES □NO 
(In answering this question, do not include: Information regarding an arrest or detention that did not result in 
conviction; information regarding referral to, and participation in, any pre-trial or post–trial diversion program; 
minor traffic violations; convictions for which the record has been judicially ordered sealed or expunged; 
marijuana-related convictions described in California Labor Code Section 432.8 that are more than two years 
old; misdemeanor convictions for which probation has been successfully completed or discharged and that have 
been judicially dismissed pursuant to California Penal Code Section 1203.4) 
If yes, please explain (a conviction will not automatically bar employment):  _____________________ 
____________________________________________________________________________ 
____________________________________________________________________________ 
____________________________________________________________________________ 
Have you ever been discharged or forced to resign from a position?   
 
 
□YES □NO 
If yes, please explain: _________________________________________________________________ 
 
___________________________________________________________________________________ 
 
___________________________________________________________________________________ 
 
___________________________________________________________________________________ 
 
Will you accept temporary work? 
 
 
 
 
 
 
□YES □NO 
 
C:\Documents and Settings\stevem.FILLMORE\Desktop\employment application.01.2008.doc 
 
 
Drivers License# _____________________ Class: ___A ___B ___C ___D     State:_________________ 
 
In case of emergency, notify: 
 
_________________________ 
______________________________ 
__________________ 
Name  
 
 
 
Telephone Number 
 
 
 
Alternate Phone 
___________________________________________________________________________________ 
Address 
 
 
 
City   
 
 
 
State  
 
Zip Code 
 
 
 
C:\Documents and Settings\stevem.FILLMORE\Desktop\employment application.01.2008.doc 
EDUCATION 
Circle Highest Grade Completed 
Name and Location of School 
Did you graduate?  
YES 
NO 
 
 
 
Did you earn a GED? 
YES 
NO 
    1 2 3 4 5 6 7 8 9 10 11 12 
 
 
 
Name and Location of Colleges, 
Universities, Trade or Vocational 
 
Major 
Did you Graduate Units Completed       Degree or Certificate 
Schools, or Training Programs 
Attended. 
YES 
NO 
Semester Quarter 
 
 
 
 
 
 
 
 
 
 
List any licenses or professional certificates you hold which apply to this position: 
 
 
 
 
 
 
 
Operation of Office Machines: 
 
 
Computers: 
 
 
Software: 
 
 
 
 
Mechanical Experience: 
 
 
 
 
 
 
 
Operation of Machinery: 
 
 
 
 
 
C:\Documents and Settings\stevem.FILLMORE\Desktop\employment application.01.2008.doc 
EXPERIENCE 
 
List all positions you have held during the past ten (10) years starting with your present or most recent position.  
Include relevant volunteer experience.  Account for all periods of unemployment.  If additional space is 
required, reverse side may be used.  Resumes may be added but cannot be substituted for this section. 
 
May we contact your present employer? 
YES 
NO 
 
 
Dates of Employment 
 
Employer's Name, Address 
and Salary Received 
Job Title(s) and Duties Performed 
and Phone Number 
 
From 
To 
Job Title: 
 
 
Mo. Yr. 
 
Mo. Yr. Duties: 
 
Salary: 
 
 
Reason for Leaving: 
 
 
 
 
Supervisor's Name: 
 
 
 
 
 
Phone No.: 
 
From 
To 
Job Title: 
 
 
Mo. Yr. 
 
Mo. Yr. Duties: 
 
Salary: 
 
 
Reason for Leaving: 
 
 
 
 
Supervisor's Name: 
 
 
 
 
 
Phone No.: 
 
From 
To 
Job Title: 
 
 
Mo. Yr. 
 
Mo. Yr. Duties: 
 
Salary: 
 
 
Reason for Leaving: 
 
 
 
 
Supervisor's Name: 
 
 
 
 
 
Phone No.: 
From 
To 
Job Title: 
 
 
Mo. Yr. 
 
Mo. Yr. Duties: 
 
Salary: 
 
 
Reason for Leaving: 
 
 
 
 
Supervisor's Name: 
 
 
 
 
Phone No.: 
C:\Documents and Settings\stevem.FILLMORE\Desktop\employment application.01.2008.doc 
 
From 
To 
Job Title: 
 
 
Mo. Yr. 
 
Mo. Yr. Duties: 
 
Salary: 
 
 
 
Reason for Leaving: 
 
 
 
 
Supervisor's Name: 
 
 
 
 
 
Phone No.: 
 
From 
To 
Job Title: 
 
 
Mo. Yr. 
 
Mo. Yr. Duties: 
 
Salary: 
 
 
 
Reason for Leaving: 
 
 
 
 
Supervisor's Name: 
 
 
 
 
 
Phone No.: 
 
From 
To 
Job Title: 
 
 
Mo. Yr. 
 
Mo. Yr. Duties: 
 
Salary: 
 
 
 
Reason for Leaving: 
 
 
 
 
Supervisor's Name: 
 
 
 
 
 
Phone No.: 
 
From 
To 
Job Title: 
 
 
Mo. Yr. 
 
Mo. Yr. Duties: 
 
Salary: 
 
 
 
Reason for Leaving: 
 
 
 
 
Supervisor's Name: 
 
 
 
 
 
Phone No.: 
 
 
C:\Documents and Settings\stevem.FILLMORE\Desktop\employment application.01.2008.doc 
REFERENCES 
Please provide name and address of two people, not relatives, who have knowledge of your skills, experience, 
and abilities. 
 
________________________________________________________________________________________ 
NAME 
ADDRESS 
CITY/STATE 
ZIP 
________________________________________________________________________________ 
PHONE 
ORGANIZATION 
TITLE 
_______________________________________________________________________________________ 
NAME 
ADDRESS 
CITY/STATE 
ZIP 
________________________________________________________________________________ 
PHONE 
ORGANIZATION 
TITLE 
 
 
ADDITIONAL INFORMATION 
 
Please provide any additional information covering your qualification(s) for this position. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
I certify that all statements made in this application are true and complete, and that 
any misstatement of material fact will subject me to disqualification or dismissal. 
 
 
 
 
_________________________________ 
 
 
 
________________________ 
 
Signature of Applicant 
Date 
 
C:\Documents and Settings\stevem.FILLMORE\Desktop\employment application.01.2008.doc 
To assist us in recruitment efforts and to enable the City to take affirmative measures to comply with 
Federal Government regulations, please complete this form and submit it with your application.  The form 
will be detached from your application and will not be forwarded to the appointing department. 
 
DATE __________________ 
 
 
POSITION APPLIED FOR ________________________________________________ 
 
I FIRST LEARNED OF THIS JOB OPENING THROUGH (Check One) 
 
__ A FRIEND OR RELATIVE 
__ AN ORGANIZATION OR GROUP (Please Specify) 
__ THE CITY'S PERSONNEL OFFICE 
__ PERSONAL CONTACT WITH A CITY RECRUITER 
__ AN OUTREACH RECRUITMENT CENTER 
__ CONTACT WITH A CITY OFFICE OTHER THAN PERSONNEL 
__ AN ADVERTISEMENT IN A NEWSPAPER 
 
 
 Which Newspaper? _________________________________________________ 
 
 
AN ADVERTISEMENT IN A MAGAZINE, PERIODICAL, OR BULLETIN 
 
 
 Which Publication?  _________________________________________________ 
 
__ OTHER MEANS (Please Specify) _________________________________________