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Employment Application
(PLEASE PRINT AND COMPLETELY ANSWER ALL QUESTIONS) The Oxnard Harbor District (“District”) fully subscribes to the principles of Equal Employment Opportunity. It is our policy to provide employment, compensation, and other benefits related to employment based on qualifications, without regard to race, color, religion, national origin, age, sex, veteran status, genetic information, disability, or any other basis prohibited by federal, state or local law. In accordance with requirements of the Americans with Disabilities Act and applicable federal, state and/or local laws, it is our policy to provide reasonable accommodation upon request during the application process to applicants in order that they may be given a full and fair opportunity to be considered for employment. As an Equal Opportunity Employer, we intend to comply fully with applicable federal, state and/or local employment laws and the information requested on this application will only be used for purposes consistent with those laws. To the extent required by applicable law, The District maintains a smoke-free workplace. POSITION APPLIED FOR: DATE: Personal Data
Name:
Last First Middle
Street Address: City: State: Zip Code:
Telephone:
Are you at least 18 years old? Yes No (If under 18, hire is subject to verification that you are of minimum legal age). What days and hours are you available to work? Will you work overtime, if required?*
Yes No
*Note: It is not necessary for you to identify unavailability for work because of religious observance or practice or any other protected classification. Subsequent to any job offer, we will consider whether a reasonable accommodation can be made.
How did you learn of the District? Have you ever applied or worked at the District before? Yes No If yes, provide dates: Are you legally authorized to work in the United States? Yes No Note: The Federal Immigration and Reform and Control Act of 1986 requires that a DHS Employment Eligibility Verification “Form I-9” be completed for every new hire and that within 3 business days of beginning work every new hire must present to the employer documentation establishing his/her identity and authorization to work. This federal requirement must be satisfied as a condition of employment. 09956.00000\29846951.1 Page 2 of 4
Driving Record
(Answer only if driving is a requirement of the job for which you are applying). Do you have a valid driver’s license? Yes No State: License No: Have you had any tickets within the past 5 years? Yes No If yes, please explain: Education
Describe any educational degrees, skills, training or experience you believe are relevant to the job applied for: Name, City and State
of Educational
Institution
Graduated If no,
Degree
Credits
Earned
Type of
Degree
Received or
Expected
Major Minor Grade Point/
Overall GPA
Yes No
High School
College or University
Technical/GED
Licenses/
Certification/Other
Employment History
Please complete for all full-time or part-time employment beginning with most recent employer. You may include as part of your employment history any verified work performed on a volunteer basis. All applicants should start with their most recent job, include military assignments and voluntary employment and provide ten (10) years of history. (A separate sheet may be attached.) You must explain any gaps in your employment history. Company Name: Telephone: Address: Name of Supervisor: May we contact: Yes No Dates Employed: From: To: State job titles and describe job duties: Reason for leaving: 09956.00000\29846951.1 Page 3 of 4
Company Name: Telephone: Address: Name of Supervisor: May we contact: Yes No Dates Employed: From: To: State job titles and describe job duties: Reason for leaving: Company Name: Telephone: Address: Name of Supervisor: May we contact: Yes No Dates Employed: From: To: State job titles and describe job duties: Reason for leaving: Company Name: Telephone: Address: Name of Supervisor: May we contact: Yes No Dates Employed: From: To: State job titles and describe job duties: Reason for leaving: Have you ever been discharged or asked to resign from employment? Yes No If yes, explain: Did you receive any discipline in your last 12 months of active employment with your previous employer?
Yes No If yes, explain: Professional References (Please list three individuals unrelated to you with whom you have worked who know your qualifications for this position.) NAME ADDRESS PHONE RELATIONSHIP
09956.00000\29846951.1 Page 4 of 4
Military (Complete only if you served in the military.) Describe any military skills, training or experience you believe are relevant to the job you applied for: Applicant’s Signature: Applicant’s Acknowledgment
I certify that the answers given herein and during the entire application process (including but not limited to information provided in resumes, attachments to this application, interviews or otherwise (if applicable)) are true and complete to the best of my knowledge. I understand that any misrepresentations, omissions of facts or incomplete answers during the application process may disqualify me from further consideration for employment. I further understand that, if employed, any misrepresentations or omissions of facts during the application process may be cause for my dismissal at any time without prior notice.
I consent to and authorize the District to contact my former employers, references, and any and all other persons and organizations for information bearing upon my qualifications for employment. I further authorize the listed employers, schools and personal references to give the District
(without further notice to me) any and all information about my previous employment and education, along with any other pertinent information they may have. Additionally, I hereby release the District, my former employers, schools, personal references, and all other persons, corporations, partnerships and associations from any and all claims, demands and liabilities arising out of or in any way pertaining to the investigation and disclosure of information bearing upon my qualifications for employment provided in good faith. I understand I may be required to qualify for employment based on additional employment criteria. For example, I may be required to take job-related tests; take a driver’s examination or take a pre- employment drug test. If I am offered employment or start work before any required test is completed, I understand that my employment is contingent on a satisfactory result on all required tests. I authorize the release of any drug/alcohol test to any state or federal authority requesting such information and in response to a valid subpoena or other legal document. I agree to sign any additional forms necessary for drug tests to be conducted.
I understand the District may obtain, without using the services of a third party investigative consumer reporting agency, public records pertaining to my character, general reputation, personal characteristics or mode of living during its evaluation of my application for employment and, if employed, during my employment. By checking the following box, I waive my right to receive copies of public records obtained by the District.
Signature: Date:
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