Dinuba Human Resources

HUMAN RESOURCES

*** *. ** ***** ***

An Equal Opportunity/ Dinuba, CA 93618

Affirmative Action Employer 559-***-****

Fax 559-***-****

www.dinuba.org

EMPLOYMENT APPLICATION

INSTRUCTIONS: Completely fill out application and sign it, print in ink or type. It is the applicant’s responsibility to ensure that the application is on file in Human Resources on the final filing date. Late applications will be rejected. POSITION APPLYING FOR:

EDUCATION

Did you graduate from High School, pass the State High School Equivalency Exam, or do you possess a G.E.D. certificate? Yes No Name of last High School attended: College or University Major Units Degree

Please list any experiences, certificates/licenses, skills or special training that are related to the position which you are applying for. ADDITIONAL INFORMATION

Are you related to any City of Dinuba employee? If yes, state name and relationship. Yes No Are you now or have you ever been employed by the City of Dinuba? Yes No Can you, after employment, submit verification of your right to work in the United States? Yes No List languages you speak fluently other than English: NAME: Last Name First Name Middle

ADDRESS: Street/P.O. Box City State Zip Code

TELEPHONE: Home Business Cell

EMAIL ADDRESS: DRIVER’S LICENSE NUMBER: CLASS: STATE: EXPIRES: Completion of this question is required only if the position for which you are applying requires the possession of a valid California Driver’s license. I meet the minimum age requirements as stated on the job announcement for this position. Yes No EMPLOYMENT HISTORY

List most recent experience first; carefully account for all employment and/or job related volunteer experience. List each job title even if employed by the same employer. Use additional sheets if necessary using the same format below. A resume may be attached, but will not be substituted for the information required in this section. Your application will be rejected if you write “See Resume”. EMPLOYER: ADDRESS: PHONE NO: POSITION TITLE: FROM (Mo/Yr.): TO (Mo/Yr.): HOURS WEEK: SUPERVISOR NAME AND TITLE: DESCRIPTION OF DUTIES: REASON FOR LEAVING: EMPLOYER: ADDRESS: PHONE NO: POSITION TITLE: FROM (Mo/Yr.): TO (Mo/Yr.): HOURS WEEK: SUPERVISOR NAME AND TITLE: DESCRIPTION OF DUTIES: REASON FOR LEAVING: EMPLOYER: ADDRESS: PHONE NO: POSITION TITLE: FROM (Mo/Yr.): TO (Mo/Yr.): HOURS WEEK: SUPERVISOR NAME AND TITLE: DESCRIPTION OF DUTIES: REASON FOR LEAVING: EMPLOYER: ADDRESS: PHONE NO: POSITION TITLE: FROM (Mo/Yr.): TO (Mo/Yr.): HOURS WEEK: SUPERVISOR NAME AND TITLE: DESCRIPTION OF DUTIES: REASON FOR LEAVING: I hereby certify that all statements made on or in connection with this application, including my training, education and experience are true and complete o the best of my knowledge and belief. I understand and agree that any misstatement or omissions of material fact herein will cause forfeiture on my part of all rights to employment with the City of Dinuba. I further understand that any offer of employment is conditional upon my ability to meet the established requirements of the job. These requirements include but may not be limited to: undergoing a pre-employment physical, including a drug screen by a physician of the City’s choosing; undergoing a fingerprint background check ; signing an oath of office; and furnishing proof of either citizenship or the legal right to work in the United States of America upon appointment. Date: Signature of applicant: DISABLED APPLICANTS

The City of Dinuba will make reasonable accommodations in the exam process to accommodate disabled applicants. If you are invited to participate in any test process and have a disability for which you require an accommodation, please contact the City of Dinuba, Human Resources. Name:

Position Applied For:

(This page will be detached from your application and filed separately) COMPLETION OF THIS SECTION IS OPTIONAL

HOW DID YOU HEAR ABOUT THIS JOB OPPORTUNITY?

Newspaper City Employee Publication Job Announcement

City Website City Email Notice Social Media Other NOTE: RACE/ETHNICITY AND GENDER INFORMATION IS FOR STATISTICAL PURPOSES ONLY AND IS NOT USED IN HIRING RACE/ETHNIC DATA

White Black Hispanic Asian

Indian American Indian or Alaskan Native Native Hawaiian or Pacific Islander Other GENDER DATA

Male Female

Contact this candidate