COUNTY OF INYO Inyo County 224 N. Edwards St. …

1 AN EQUAL OPPORTUNITY EMPLOYER Rev18. RETURN TO: 760-878-0377- Office COUNTY OF INYO Inyo COUNTY Personnel 224 N. Edwards St. 760-878-0465- Fax P. O. Box 249. APPLICATION FOR EMPLOYMENT Independence, CA 93526. NAME: (LAST, FIRST, MIDDLE INITIAL) POSITION APPLIED FOR (please submit one application per position): MAILING ADDRESS (Street, City & Zip): DATE: TELEPHONE: DO YOU HAVE A DRIVER'S LICENSE NOW? Yes No IF YES, WHAT KIND: Class A Class B Class C. Have you previously been employed by Inyo COUNTY ? Yes No Are you a CalPers Retiree? Yes No List any family members employed by Inyo COUNTY : _____. Were you in the Armed Forces? Yes No If requesting veteran's preference, you must attach a copy of your DD214 prior to the final filing date.

2 BRANCH_____from_____to _____. COMPLETE ONLY IF THE POSITION YOU ARE APPLYING FOR STATES AN AGE REQUIREMENT: Birthdate : DAY _____ YEAR _____. Do you need reasonable accommodation to take an interview or written test? Yes No Were you ever discharged, released during probation, or have you resigned under pressure or unfavorable circumstances from any employment? Yes No If yes, explain: EDUCATION: Highest grade completed: HIGH SCHOOL COURSE GRADUATED. Yes No JUNIOR COLLEGE/COLLEGE MAJOR UNITS DATE GRAD. DEGREE. UNIVERSITY/GRADUATE SCHOOL MAJOR UNITS DATE GRAD. DEGREE. PROFESSIONAL LICENSES OR REGISTRATIONS HELD: COMPUTER KNOWLEDGE: DO YOU SPEAK ANY LANGUAGE OTHER THAN ENGLISH? Yes No IF YES, WHICH ONE?

3 WILL YOU ACCEPT TEMPORARY WORK? Yes No WILL YOU ACCEPT PART-TIME WORK? Yes No LIST APPRENTICESHIP, TRADE, VOCATIONAL, BUSINESS SCHOOL, MANPOWER TRAINING OR ANY OTHER SPECIAL TRAINING YOU HAVE HAD. INCLUDE TYPE, WHERE ACQUIRED, DATES. AND WHETHER COMPLETED SUCCESSFULLY. LIST ANY VOLUNTEER SERVICE THAT MAY BE RELATED TO THE POSITION FOR WHICH YOU ARE APPLYING. (LIST IN DETAIL - USE ADDITIONAL PAGES IF NECESSARY). CERTIFICATE OF APPLICANT (Read c a r e f u l l y b e f o r e s i g n i n g - A p p lic a t io n mu s t b e s ig n e d in o r d e r t o b e e lig ib le ). I h e r e b y c e r t i f y t h a t a l l s t a t e me n t s ma d e i n t h i s a p p l i c a t i o n a r e t r u e , a n d I a g r e e a n d u n d e r s t a n d t h a t a n y mi s s t a t e me n t o f m a t e r i a l f a c t s h e r e i n wi l l c a u s e f o r f e i t u r e o n my p a r t o f a n y e mp l o y me n t a s a n e mp l o y e e i n t h e s e r v i c e o f t h e Co u n t y o f I n y o.

4 I f u r t h e r g i v e p e r mi s s i o n t o t h o r o u g h l y i n v e s t i g a t e my r e f e r e n c e s , wo r k r e c o r d , e d u c a t i o n a n d o t h e r ma t t e r s r e l a t e d t o my s u i t a b i l i t y f o r e mp l o y me n t a n d a u t h o r i ze d i s c l o s u r e o f a n y a n d a l l i n f o r ma t i o n r e l a t e d t o my wo r k r e c o r d s , wi t h o u t g i v i n g me p r i o r n o t i c e o f s u c h d i s c l o s u r e . I n a d d i t i o n I h e r e b y r e l e a s e I n y o Co u n t y , my f o r me r e mp l o y e r s , a n d a l l o t h e r p e r s o n s f r o m a n y a n d a l l c l a i ms , d e ma n d s , o r l i a b i l i t i e s a r i s i n g o u t o f o r i n a n y wa y r e l a t e d t o s u c h d i s c l o s u r e.

5 I f u r t h e r a g r e e t o b e f i n g e r p r i n t e d , t o s u b mi t t o a c o mp l e t e me d i c a l e x a mi n a t i o n b y a Co u n t y p h y s i c i a n , u p o n e mp l o y me n t , t o f u r n i s h s u c h p r o o f o f a g e a n d c i t i ze n s h i p a s ma y b e d i r e c t e d . Signature_____. DO NOT WRITE IN THIS BLOCK - COMPLETE EMPLOYMENT RECORD ON REVERSE. Written: Interview Date: Interview Time: ALL INFORMATION CONTAINED ON OR ATTACHED TO THE EMPLOYMENT APPLICATION IS CONSIDERED CONFIDENTIAL INFORMATION AND IS NOT SUBJECT TO PUBLIC DISCLOSURE WITHOUT THE. CANDIDATE'S EXPRESSED PERMISSION. E M P L O Y M E N T R E C O R D : Beginning with your present or most recent job, show a complete record of your employment.

6 Describe in detail any aspects of your experience or activities that are particularly appropriate for the position for which you are applying. It is not acceptable to complete the application with statements like See/Refer to resume or See attached . FROM (Mo - Yr) TO (Mo - Yr) JOB TITLE OR OCCUPATION. EMPLOYER'S NAME AND ADDRESS REASON FOR LEAVING. DESCRIPTION OF DUTIES: YOUR SUPERVISOR'S NAME PART-TIME FULL-TIME. FROM (Mo - Yr) TO (Mo - Yr) JOB TITLE OR OCCUPATION. EMPLOYER'S NAME AND ADDRESS REASON FOR LEAVING. DESCRIPTION OF DUTIES: YOUR SUPERVISOR'S NAME PART-TIME FULL-TIME. FROM (Mo - Yr) TO (Mo - Yr) JOB TITLE OR OCCUPATION. EMPLOYER'S NAME AND ADDRESS REASON FOR LEAVING. DESCRIPTION OF DUTIES: YOUR SUPERVISOR'S NAME PART-TIME FULL-TIME.

7 FROM (Mo -Yr) TO (Mo - Yr) JOB TITLE OR OCCUPATION. EMPLOYER'S NAME AND ADDRESS REASON FOR LEAVING. DESCRIPTION OF DUTIES: YOUR SUPERVISOR'S NAME PART-TIME FULL-TIME. Use additional sheets if necessary to continue your employment history or to describe in greater detail any aspects of your experience or activities that are particularly appropriate for the position for which you are applying. Inyo COUNTY Personnel Department Employment Application Form Page 3. THIS PORTION OF THE APPLICATION IS NOT AVAILABLE TO AN INTERVIEW BOARD. AN EQUAL OPPORTUNITY-AFFIRMATIVE ACTION EMPLOYER - Please help us comply with the state and Federal law by completing this section. While you are not required to complete this section, you should know that if you leave it blank we have the right to enter data for this purpose based upon our visual assessment.

8 To demonstrate that we meet equal employment opportunity requirements, periodically we must report statistical information about applicants and employees to the California and United States Governments. This information will be kept separate and confidential and will not be used in any unlawful way to make any employment decision. The COUNTY of Inyo is an Affirmative Action Employer. NAME OF APPLICANT_____. DATE _____. TITLE OF POSITION APPLIED FOR _____. Date of Birth _____/_____/_____. Drivers License: State_____ Number _____. Social Security Number: _____. Email Address: _____. Please answer below based upon how you are known in your community. We understand that it may be difficult to choose single ethnic identity if you have a multicultural heritage.

9 Nevertheless to comply with legal guidelines, we would like you to choose only one. Check Appropriate Box: Male Female WHITE (not of Hispanic Origin): All persons not BLACK (not of Hispanic origin): All persons HISPANIC: All persons of Mexican, Puerto Rican, classified into one of five specific ethnic minority having origin in any of the black racial groups. Cuban, Central or South American, or another categories that follow. Spanish culture or origin, regardless of race. ASIAN or Pacific Islanders other than Filipinos FILIPINO All persons having origins in the AMERICAN INDIAN or Alaskan Native. All per- All persons having origins in any of the original peoples of the Philippine Islands.

10 Sons having origins in any of the original peoples of the Far East, Southeast Asia, or the peoples of North America. Pacific Islands. For example, includes China, Japan, Korea, Samoa, the Indian Subcontinent and the Middle East.