City of Clayton
6000 Heritage Trail
Clayton, Ca 94517
925.673-7300
www.ci.clayton.ca.us

EMPLOYMENT APPLICATION

The City of Clayton is an Equal Opportunity Employer and hires on the basis of qualifications (training and experience), and ability to perform effectively in the specified position. We do not and will not discriminate on the basis of race, color, religion, gender, etc., nor for disabilities that can reasonably be accommodated.

Position applying for: __________________________________________________________________
Name (Last First Middle): _______________________________________________________________
Mailing Address: ______________________________________________________________________
City State Zip Home Phone: ______________________________________
Message Phone: _____________________________________ Date of Birth:_______________
Drivers License Number:_______________________ State Issued:___________ Expiration:______________

Are you a citizen of the United States?
_____ Yes ______No
If not, do you have a work permit from the U.S. Immigration and Naturalization Service?
_____Yes _____No
Permit No. _________________ (Proof required)
Are you over 18 years of age? ____Yes _____No If no, can you submit a work permit from school? _____Yes _____No
Police Officer and Trainee candidates only:
Are you at least 21 years of age: _____Yes _____No
If no, date you will become 21: ________________________
Are you a graduate of a POST Basic Academy? _____Yes ______No
Are you currently attending a POST Basic Academy? _____Yes _____No
List any other names under which you may have worked or education records may be filed: ___________________________________________

Have you ever been convicted of a crime that resulted in imprisonment, probation, or a fine of $50 or more? [DO NOT include convictions settled in juvenile court or under a Youth Offender Law or convictions that are over two (2) years old for violations of Health and Safety Code Sections 11357, 11360, 11364, 11365 or 11550, as these statutes related to marijuana prior to January 1, 1976, or violations of a statutory predecessor to any of these statutes. A conviction record will not necessarily bar you from employment. Each case will be given individual consideration based on job relatedness]. Your answer may be checked and an untrue answer is grounds for disqualification: _________Yes _________No If yes, give date, place, and disposition of each case: _____________________________________________________________________________________________________ _____________________________________________________________________________________________________.

 

 

EDUCATION AND TRAINING
Circle Highest Grade Completed: 8 9 10 11 12 G.E.D.        College 1 2 3 4        Graduate Work? Yes No
Colleges or Universities attended Location From To Units Completed Degree/Certificates Major
 
 
 
 
 
 
 
 

Office Skills and Office Machines you can operate: ___________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________
Heavy Equipment and Field Tools you can operate: ___________________________________________________________ _____________________________________________________________________________________________________

 

Special Certificates:

Title

Date Issued Date Expires Number
Please list three references with phone numbers: 1.________________________________________________________________________________________ 2.________________________________________________________________________________________ 3.________________________________________________________________________________________
Signature: _________________________________________
Date: ________________________             Version Date: June 2004

 

 

 

 
EMPLOYMENT RECORD:
Begin with present or most recent position. List work record for past five years, include any other pertinent experience. This section must be completed. A resume may be attached, but does not substitute for completing this section.
. This section must be completed. A resume may be attached, but does not substitute for completing this section
From: Month/Year                                   To: Month/Year Title of Position:
Last Salary/Pay Scale:
Name and address of employer:

Name of supervisor: ____________________

No. supervised: ________________________

Phone No: ____________________________

May we contact? ______Yes _______No

Duties included:







Reason for Leaving: ____________________
From: Month/Year                                   To: Month/Year Title of Position:
Last Salary/Pay Scale:
Name and address of employer:

Name of supervisor: ____________________

No. supervised: ________________________

Phone No: ____________________________

May we contact? ______Yes _______No

Duties included:







Reason for Leaving: ____________________
From: Month/Year                                   To: Month/Year Title of Position:
Last Salary/Pay Scale:
Name and address of employer:

Name of supervisor: ____________________

No. supervised: ________________________

Phone No: ____________________________

May we contact? ______Yes _______No

Duties included:







Reason for Leaving: ____________________
From: Month/Year                                   To: Month/Year Title of Position:
Last Salary/Pay Scale:
Name and address of employer:

Name of supervisor: ____________________

No. supervised: ________________________

Phone No: ____________________________

May we contact? ______Yes _______No

Duties included:







Reason for Leaving: ____________________

 

 

The information in this application is correct to the best of my knowledge. I understand and agree that any intentional misstatement or omission of material fact may be cause for disqualification or termination of employment. I understand that the City of Clayton will perform a background investigation based on the information given in my application, including but not limited to criminal and driving record searches, employment and education verification, and relevant citizenship or immigration status; and that such investigations may result in disqualification from employment with the City. Except as otherwise noted, previous employers are authorized to give any and all information concerning my previous employment. I understand that if offered a position with the City of Clayton I may be required to submit to medical and/or psychological examinations, and that any offer of employment is conditioned on the results of such examinations.