APPLICATION FOR EMPLOYMENT Personnel Department 7100 S. Garfield Boulevard Bell Gardens, CA 90201 (562) 806-7700 Main line An Equal Opportunity/Affirmative Action Employer Date and Time Stamp (Human Resources Use Only) POSITION APPLIED FOR: Job ID# PERSONAL INFORMATION LAST NAME FIRST NAME MIDDLE INITIAL PRIMARY TELEPHONE NUMBER ADDRESS: (NUMBER STREET APT #) ALTERNATE TELEPHONE NUMBER CITY STATE ZIP CODE E-MAIL ADDRESS Are you related (by blood or marriage) to any Bell Gardens City employee? No Yes (if yes, complete information below) EMPLOYEE NAME RELATIONSHIP DEPARTMENT THEIR JOB TITLE Have you ever been terminated or resigned in lieu of termination? No Yes (if yes, complete information below) DATE POSITION / JOB TITLE EXPLANATION / REMARKS Are you willing to work: ** For Positions that Require Driving ** Full Time? No Yes Days? No Yes Do you have a valid California driver s license? no yes Part Time? No Yes Nights? No Yes Driver License Information Temporary? No Yes Weekends? No Yes State Number Seasonal? No Yes Holidays? No Yes On-call? No Yes Shift Work? No Yes Class Endorsement Expiration Date (xx/xx/xxxx) / / Public Employees Retirement System (PERS) Status ** Police Officer / Recruit Applicants only ** Are you currently a member of PERS? No Yes Are you a U.S. Citizen or a permanent resident alien who is Have you ever been a member of PERS? No Yes eligible for and has applied for citizenship? No Yes Did you graduate from high school? Did you earn a GED? No No HIGEST GRADE COMPLETED 1 2 3 4 5 6 7 8 9 10 11 12 EDUCATION AND TRAINING Yes Yes Name of High School (or Institution that provided GED) City and State *** Must attach copies of all degrees and certificates received at time of application *** Names of Colleges, Universities and/or Military Academies attended Location () Number of Units Semester Quarter Major / Emphasis Graduated? 1) No Yes Degree / Certificate Received 2) No Yes 3) No Yes Trade or Vocational Schools attended Location Credit Type (#) Units Hours Area of Study/Trade Degree / Certificate 1) No Yes 2) No Yes HR Review Dept Review Has all required License(s) No Yes FOR OFFICE USE ONLY Screening Disposition NQ DEF MSR MMR AMQ Remarks Page 1 of 5
- READ CAREFULLY BEFORE BEGINNING THIS SECTION - 1. Read the experience requirements in the job bulletin before completing this section. 2. Begin with your most recent job. List different positions with the same employer separately. 3. Account for all time within the last 10 years, including military, self-employment, volunteer and any time you were not employed for any reason. Employment and personal references may be verified. 4. List all periods of employment with the City of Bell Gardens, regardless of when they occurred. 5. Fill out completely. Do not leave any blanks. Attach an additional sheet if you need more space. 6. Incomplete applications may not receive full consideration. 7. Resumes are NOT accepted in place of any part of this application. However, you may include a résumé in addition to this application for consideration. 8. May we contact your present employer? Yes No EXPERIENCE Reason for leaving or wanting to leave if presently employed: Page 2 of 5
JOB ID# POSITION APPLIED FOR: APPLICANT NAME (print): EXPERIENCE (Cont d): You may attach a copy of this page to reflect additional information. Reason for leaving or wanting to leave if presently employed: Periods Of Unemployment Page 3 of 5
CERTIFICATION AND WAIVER CERTIFICATION: PLEASE READ BEFORE SIGNING. IF NOT SIGNED, APPLICATION MAY BE REJECTED. I certify under penalty of perjury that the information I entered on this application is true and complete to the best of my knowledge. I understand that the City may reject my application if it discovers any issue(s)/incident(s) which occurred during my current or former employment, and I did not disclose such on this job application. I also understand that any false, incomplete, or incorrect statements may result in my disqualification from the application process, removal from an eligible list or dismissal from employment with the City. SIGNATURE: DATE: Page 4 of 5
JOB ID# POSITION APPLIED FOR: APPLICANT NAME (print): VOLUNTARY STATISTICAL INFORMATION This information is requested to assist the City in complying with Federal and State reporting requirements. The data you provide will be detached from your application and used only for research and statistical purposes. All information in this section is confidential; no one connected with the hiring process will have access to this information. DEMOGRAPHICS RACE / ETHNICITY GENDER: Male Female AGE GROUP: Under 21 21-39 40 and over Check only one (primary) race / ethnicity Native American / Alaskan Native Asian Or Pacific Islander Black, African American Hispanic White, Caucasian RACE / ETHNICITY DEFINITIONS If multi-racial, please check all that apply Native American / Alaskan Native Asian Or Pacific Islander Black, African American Hispanic White, Caucasian Definitions for Race/Ethnicity as defined by the United States Equal Employment Opportunity Commission (EEOC). This information is used for reporting purposes only, as required by the EEOC. AMERICAN NATIVE/ ALASKAN NATIVE ASIAN OR PACIFIC ISLANDER BLACK, AFRICAN AMERICAN HISPANIC WHITE, CAUCASIAN All persons having origins in any of the original peoples of North America, and who maintain cultural identification through tribal affiliation or community recognition. All persons having origins in any of the original peoples of the Far East, Southeast Asia, the Indian subcontinent, or the Pacific Islands. (e.g., China, Japan, Korea, Samoa and the Philippine Islands) (Not of Hispanic origin) All persons having origins in any of the racial groups of Africa. All persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of race. (Not of Hispanic origin) All persons having origins in the original peoples of Europe, North Africa or the Middle East. Bell Gardens website I FIRST LEARNED ABOUT THIS JOB OPENING THROUGH (check all that apply) Job posting at Bell Gardens City Hall Received Bell Gardens interest card in mail Job Posting at other government agency Friend or relative City employee: Other: Job Fair (specify location/event name): College/university job posting (school): Career Center (organization or school): Internet job posting (specify site): Newspaper / Magazine ad (specify): Newsletter ad (specify organization): Business/Networking Group: E-mail blast (specify sender/group): Page 5 of 5