THE NAVAJO NATION

1 MIDDLE INITIAL DRIVER'S LICENSE NUMBER TYPECLASS:ARE YOU A VETERAN? DO YOU WISH TO CLAIM veterans ' PREFERENCE?If not previously submitted, please provide a copy of DD Form 214/215If Yes, please attach an Application for veterans ' employment Preference TOHIGH SCHOOLCOLLEGE/UNIVERSITYREVISED 09-16-16 PAGE 1 OF 4 COLLEGE/UNIVERSITYSTATE TECHNICAL/VOCATIONAL/BUSINESS SCHOOLE-MAIL ADDRESSIF YES, INDICATE CENSUS NUMBEREDUCATIONPOSITION NUMBER ARE YOU AN ENROLLED MEMBER OF THE NAVAJO TRIBE?TELEPHONE NUMBERMESSAGE NUMBER LIST JOB RELATED SKILLS:REQUISITION NUMBER POSITION INFORMATIONTHE NAVAJO NATION employment Application PERSONAL INFORMATIONEXPIRATION DATE (MM/DD/YYYY)FIRST NAME ZIP CODE LIST ADDITIONAL JOB RELATED TRAINING - INCLUDE DATES OF TRAINING ARE YOU CURRENTLY EMPLOYED WITH THE NAVAJO NATION ?DATES ATTENDED(MM/YY)POSITION TITLE NAME AND LOCATION OF SCHOOL MAJOR/MINORFROM GED/DIPLOMA/DEGREE RECEIVEDSOCIAL SECURITY NUMBER MAILING ADDRESS CITYSTATE LAST NAME OTHER NAMES USED IF APPLICABLE DATE OF BIRTH (MM/DD/YYYY)The NAVAJO NATION gives preference to eligible and qualified applicants inaccordance with the NAVAJO Preference in employment Act (NPEA) and the veterans ' Preference IF NO, STATE NATIONALITYFor DPM Use Only YES NO YES NO YES NO YES NO If not previously submitted, please attach copy of CIB (REQUIRED) CDL OPERATOR PLEASE PRINT ALL INFORMATION NAME/ DEPARTMENT: NAME/ DEPARTMENT:REVISED 09-16-16 PAGE 2 OF 4 employment HISTORY(Do not indicate "See Resume".)

2 Begin with current or most recent position.)JOB TITLEDATES EMPLOYED (MM/DD/YYYY)Do not repeat names of supervisors listed under work :EMPLOYER'S NAME AND MAILING ADDRESSRELATIONSHIP:* A conviction does not automatically disqualify you, however, an incomplete answer will result in an incomplete application * A conviction does not automatically disqualify you, however, an incomplete answer will result in an incomplete application HAVE YOU EVER BEEN CONVICTED OF A MISDEMEANOR INVOLVING MORAL TURPITUDE? * IF YES, GIVE DATE AND REASONADDITIONAL employment INFORMATIONDESCRIBE DUTIES AND RESPONSIBILITIESADDRESS ARE YOU RELATED TO ANYONE CURRENTLY EMPLOYED WITH THE NAVAJO NATION ?DO YOU HAVE ANY PHYSICAL CONDITION(S) WHICH MAY CHALLENGE YOUR ABILITY TO * IF YES, GIVE BRIEF DESCRIPTION PERFORM THE RESPONSIBILITIES OF THE JOB FOR WHICH YOU ARE APPLYING. * An incomplete answer will result in an incomplete applicationTELEPHONE NUMBERHAVE YOU EVER BEEN CONVICTED OF A FELONY?

3 * IF YES, GIVE DATE AND REASON. ATTACH ADDITIONAL SHEET IF NECESSARYNAMEREFERENCES: List three persons who are not related to you and who have definite knowledge of your qualifications for the position you are applying for. IMMEDIATE SUPERVISOR:TELEPHONE NUMBERREASON FOR LEAVINGJOB TITLEDATES EMPLOYED (MM/DD/YYYY)EMPLOYER'S NAME AND MAILING ADDRESSDESCRIBE DUTIES AND RESPONSIBILITIESTELEPHONE NUMBERREASON FOR LEAVINGIMMEDIATE SUPERVISOR: YES NO YES NO YES NO FROM TO FROM TO YES NO DATEPAGE 3 OF 4 DESCRIBE DUTIES AND RESPONSIBILITIESJOB TITLEEMPLOYER'S NAME AND MAILING ADDRESSDATES EMPLOYED (MM/DD/YYYY)EMPLOYER'S NAME AND MAILING ADDRESSJOB TITLEIMMEDIATE SUPERVISOR:DESCRIBE DUTIES AND RESPONSIBILITIESJOB TITLEEMPLOYER'S NAME AND MAILING ADDRESSIMMEDIATE SUPERVISOR:REASON FOR LEAVINGDATES EMPLOYED (MM/DD/YYYY)TELEPHONE NUMBERIMMEDIATE SUPERVISOR.

4 DESCRIBE DUTIES AND RESPONSIBILITIESREVISED 09-16-16 PRE- employment STATEMENT - PLEASE READ CAREFULLY AND SIGN THE STATEMENT BELOWSIGNATURETHEINFORMATIONTHATI HAVE PROVIDEDONTHISAPPLICATIONISTRUE ,ORANYOTHERMATERIALS USEDINTHEAPPLICATION PROCESS,ORINFORMATIONOFFEREDDURING ANYINTERVIEWS,CANBEJUSTIFICATIONFORREFUS ALOFEMPLOYMENT,ORIFEMPLOYED, BELOW AUTHORIZES THE NAVAJO NATION TO CONTACT ANY OF MY PRIOR EMPLOYERS FOR REFERENCE UNDERSTAND THATI MAYBE SUBJECTTOA BACKGROUND CHECK, ANDHEREBYAUTHORIZENAVAJONATIONTOINVESTIG ATEMYBACKGROUNDTODETERMINEANY ANDALLINFORMATIONOFCONCERNASTOMYRECORD, WHETHERSAMEISOFRECORDOR NOT,ANDI RELEASE EMPLOYERSANDPERSONS NAMEDINMYAPPLICATION FROM ALL LIABILITY FOR ANY DAMAGES ON ACCOUNT OF HIS/HER FURNISHING SAID INFORMATION. ADDITIONALLY,YOUAREHEREBYAUTHORIZEDTOMAK EANYINVESTIGATIONOFMYPERSONALHISTORY, EDUCATIONAL BACKGROUND,MILITARYRECORD,MOTORVEHICLE RECORDS, CRIMINAL RECORDS AND CREDIT HISTORY THROUGHAN INVESTIGATIVEORCREDIT THE RELEASE OF THIS INFORMATION BY THE APPROPRIATE AGENCIES TO THE INVESTIGATING SERVICE.

5 TELEPHONE NUMBERREASON FOR LEAVINGDATES EMPLOYED (MM/DD/YYYY)TELEPHONE NUMBERREASON FOR LEAVINGIMMEDIATE SUPERVISOR:DESCRIBE DUTIES AND RESPONSIBILITIESTELEPHONE NUMBERREASON FOR LEAVINGDATES EMPLOYED (MM/DD/YYYY)JOB TITLEEMPLOYER'S NAME AND MAILING ADDRESSFROM TO FROM TO FROM TO FROM TO REVISED 09-16-16 PAGE 4 OF 4 IMMEDIATE SUPERVISOR:DATES EMPLOYED (MM/DD/YYYY)JOB TITLEDESCRIBE DUTIES AND RESPONSIBILITIESTELEPHONE NUMBERREASON FOR LEAVINGIMMEDIATE SUPERVISOR:DATES EMPLOYED (MM/DD/YYYY)JOB TITLEEMPLOYER'S NAME AND MAILING ADDRESSTELEPHONE NUMBERREASON FOR LEAVINGDATES EMPLOYED (MM/DD/YYYY)JOB TITLEDESCRIBE DUTIES AND RESPONSIBILITIESEMPLOYMENT HISTORY- CONTINUEDEMPLOYER'S NAME AND MAILING ADDRESSTELEPHONE NUMBERREASON FOR LEAVINGDATES EMPLOYED (MM/DD/YYYY)JOB TITLEEMPLOYER'S NAME AND MAILING ADDRESSIMMEDIATE SUPERVISOR:DESCRIBE DUTIES AND RESPONSIBILITIESEMPLOYER'S NAME AND MAILING ADDRESSTELEPHONE NUMBERREASON FOR LEAVINGDESCRIBE DUTIES AND RESPONSIBILITIESIMMEDIATE SUPERVISOR:FROM TO FROM TO FROM TO FROM TO