APPLICATION FOR EMPLOYMENT

Type of School

Name and Location

Attend From

Number of Units

Special Courses

Degree Diploma

High School

Graduate School

Technical or Professional

Others Trade/Military

APPLICATION FOR EMPLOYMENT

ROSSMOOR COMMUNITY SERVICES DISTRICT

3001 Blume Dr.

Rossmoor, CA 90720

Telephone (562) 430-3707

Equal Opportunity Employer: The Rossmoor Community Services District (RCSD) considers all applicants for all positions without regard to race, sex, religion, sexual orientation, national origin, ancestry, color, creed, age, marital status, disability, or any other legally protected status. At the time of hire, the documentation requirements of the immigration Reform and Control Act of 1986 must be met.

Resumes may be attached but not accepted in lieu of the employment application. Failure to complete all items on this application may result in your disqualification.

INSTRUCTIONS: 1. Print with black ink or use a typewriter;

2. Avoid any references to race, color, religion, national origin, sex, or age;

3. False statements are cause for rejection of application or dismissal from position.

Date: ____________________________

1. POSITION APPLIED FOR: ____________________________________________________________________________

2. NAME: ____________________________________________________________________________________________

Last First Middle

3. ADDRESS: _________________________________________________________________________________________

Number Street

_________________________________________________________________________________________

City State Zip Code

4. HOME PHONE ( ) _______________________________ CELL PHONE ( ) ________________________________

5. DO YOU HAVE A CURRENT/VALID CALIFORNIA DRIVERS LICENSE? YES NO

(NOTE: If hired, a DMV Report and proof of license and insurance may be required)

6. ARE YOU LEGALLY ELIGIBLE TO WORK IN THE UNITED STATES? YES NO

7. WERE YOU EVER DISCHARGED OR ASKED TO RESIGN FROM ANY POSITION? YES NO

IF YES, LIST THE CIRCUMSTANCES AND EMPLOYER ON A SEPARATE SHEET AND ATTACH.

8. HAVE YOU PREVIOUSLY BEEN EMPLOYED BY THE RCSD? YES NO

9. ARE YOU RELATED TO ANYONE WORKING FOR THE RCSD? YES NO

IF YES, IN WHAT CAPACITY? ______________________________ RELATIONSHIP _____________________________

10. ARE YOU CAPABLE OF PERFORMING, WITH OR WITHOUT REASONABLE ACCOMMODATION, THE ACTIVITIES INVOLVED IN THE POSITION FOR WHICH YOU HAVE APPLIED? YES NO

11. DO YOU HAVE A NEED FOR SPECIAL TESTING ACCOMMODATIONS DUE TO A DISABILITY? YES NO

IF YES, EXPLAIN: ______________________________________________________________________________________

12. AS AN ADULT (AGE 18), HAVE YOU EVER BEEN CONVICTED OF A MISDEMENOR OR FELONY? IF YES, LIST THE DATE, LOCATION OF CONVICTION AND THE PENAL CODE VIOLATION NUMBER ON A SEPARATE SHEET AND ATTACH. (Convictions are evaluated for each position and are not necessarily disqualifying.) YES NO

13. LIST ANY PROFESSIONAL OR TECHNICAL ORGANIZATION OF WHICH YOU ARE A MEMBER.

_____________________________________________________________________________________________________

14. LIST ANY JOB RELATED EDUCATION OR TRAINING.

15. EMPLOYMENT RECORD: Provide a complete employment history beginning with your current or most recent job. If more space is needed, attach additional sheets. Include any job-related military assignments and volunteer activities. Only those jobs listed will be considered in determining your eligibility. This section must be fully completed.

From To Name of Company and Address Salary

Mo.

Yr.

Mo.

Yr.

Start

Final

Job Title ______________________________________________________________________________________________

Supervisor’s Name/Title _______________________________________________________ May we contact? Yes No

Description of Duties and Accomplishments __________________________________________________________________

______________________________________________________________________________________________________

Reason for Leaving ______________________________________________________________________________________

From To Name of Company and Address Salary

Mo.

Yr.

Mo.

Yr.

Start

Final

Job Title ______________________________________________________________________________________________

Supervisor’s Name/Title _______________________________________________________ May we contact? Yes No

Description of Duties and Accomplishments __________________________________________________________________

______________________________________________________________________________________________________

Reason for Leaving ______________________________________________________________________________________

EMPLOYMENT RECORD CONTINUED:

From To Name of Company and Address Salary

Mo.

Yr.

Mo.

Yr.

Start

Final

Job Title ______________________________________________________________________________________________

Supervisor’s Name/Title _______________________________________________________ May we contact? Yes No

Description of Duties and Accomplishments __________________________________________________________________

______________________________________________________________________________________________________

Reason for Leaving ______________________________________________________________________________________

From To Name of Company and Address Salary

Mo.

Yr.

Mo.

Yr.

Start

Final

Job Title ______________________________________________________________________________________________

Supervisor’s Name/Title _______________________________________________________ May we contact? Yes No

Description of Duties and Accomplishments __________________________________________________________________

______________________________________________________________________________________________________

Reason for Leaving ______________________________________________________________________________________

16. OTHER COMMENTS ABOUT YOUR CAREER OBJECTIVES OR ABILITIES WHICH MAY PERTAIN TO THE POSITION.

______________________________________________________________________________________________________

APPLICANT CERTIFICATION: All answers and statements in this application are true and complete to the best of my knowledge and belief. I understand that untruthful or misleading answers are cause for rejection of this application, removal of name from an eligible list, or dismissal from district employment. I authorize investigation of all statements in this application for employment as may be necessary in arriving at an employment decision. I understand that I may be requested to submit proof of qualifications at a later date. If upon checking these you determine that I do not meet specific requirements, I understand that I will be disqualified.

In order that the District may verify the accuracy of the information contained in my application, I hereby authorize any former employer, its employees or representatives, or any person listed as a reference to provide any and all information they deem appropriate regarding my employment and job performance, references, education or training, and criminal history, including driving record to the RCSD, and any of its employees, representatives, and agents. I understand that the District has a right to obtain criminal history information. This information may be provided either verbally or in writing. In addition to authorizing the release of any information regarding my employment, I hereby fully waive any rights or claims I have or may have against any former employer, its employees and representatives, or any person listed as a reference, and release any former employer, its employees and representative, former educational institution, or any person listed as a reference from any an all liability, claims, or damages that may directly or indirectly result form the use, disclosure, or release of such information by any person or party, whether such information is favorable or unfavorable to me. I am aware that fingerprinting may be required after an offer of employment. In addition, I am aware that after an offer of employment has been extended, I may be required to submit to a medical examination that includes a drug and/or alcohol analysis. I also understand that failure to submit to or satisfactorily complete this examination may result in any offer of employment being withdrawn.

APPLICANTS SIGNATURE __________________________________________________ DATE ______________________

ELECTION TO RECEIVE/NOT RECEIVE PUBLIC RECORDS

[California Civil Code section 1786.53]

I am aware that the Rossmoor Community Services District may obtain public records regarding me for employment purposes, including but not limited to evaluation for employment, assignment, and/or promotion as well as conducting investigations into possible misconduct.

I acknowledge that the term public records as used herein are limited to records of: arrest, indictment, conviction, civil judicial action, tax lien, or outstanding judgment.

Check one box only:

I hereby elect to receive any public records which may be obtained by the Rossmoor Community

Services District for employment purposes under Civil Code section 1786.53.

I hereby elect not to receive any public records which may be obtained by the Rossmoor

Community Services District for employment purposes under Civil Code section 1786.53.

____________________________ __________________________________________________________

Date Name (Print)

_____________________________________________________________________

Signature

This form must be completed as part of the application packet.