Untitled Document

					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.