CITY OF CARSON 701 East Carson Street P. O. Box 6234 Carson, CA 90749

Telephone (310) 952-1736 Fax (310) 830-2471

Date Received:

Reviewed by:

An Equal Opportunity Employer

EMPLOYMENT APPLICATION

POSITION APPLIED FOR

The application is part of the examination process for all City of Carson jobs. A separate and complete application must be filled out for each position for which you are applying. Failure to complete this application form completely, accurately and legibly may be cause for disqualification of your application. Résumés or attachments may be included but will not be substituted for a city of Carson employment application form. Read the Employment Announcement thoroughly, and clearly state your qualifications. When submitting a hard copy, PRINT legibly in black or blue ink. It is your responsibility to NOTIFY Human Resources PROMPTLY IF YOU HAVE A CHANGE OF ADDRESS, TELEPHONE NUMBER, EMAIL OR EMPLOYER.

Do you possess a valid California Driver's License? YES NO

1. Are you related to anyone who works for the City of Carson? YES NO

If yes, name Department Relationship

2. Are you willing to work overtime if this position requires it? YES NO

3. If hired, could you submit verification of your legal right to work in the U.S.? YES NO

EDUCATION AND TRAINING

Name of College, University, or Trade School Attended

Location (City & State) Major Credits/Units/Hours Completed

Degree or Certificate

CITY USE ONLY

http://ci.carson.ca.us

Social Security No

Name of High School Location (City & State) Diploma GED

Received by:

NAMQ MQ QUAL INCOMPLETEOTHER

Last Name First Name Middle Name

Home Address (No., Street, Apt. No. )

City State Zip Code

Home Phone Cell Phone Email

Driver's License No Class State Expiration Date

NO YES NO YES

Type of Recruitment

City of Carson Employment Application

List you most recent work experience first. Account for all employment, volunteer experience, and internships for the last ten (10) years. You may attach additional sheets as needed. You may attach a résumé but this section must be completed. DO NOT WRITE “SEE RÉSUMÉ” in any part of employment history section. Failure to complete the employment history information will result in disqualification of your application.

May we contact your present employer? YES NO May we contact your previous employers? YES NO

Have you ever been discharged for misconduct or unsatisfactory job performance or asked to resign? YES NO

If yes, please explain

From (Mo/Yr) Present or Last Employer Supervisor: Name & Phone

To (Mo/Yr) Address - Number and Street City State ZipSalary

Monthly

Hourly

Hrs. Per Wk Job Title Reason for Leaving

Duties:

From (Mo/Yr) Previous Employer Supervisor: Name & Phone

To (Mo/Yr) Address - Number and Street City State ZipSalary

Monthly

Hourly

Job Title Reason for Leaving Hrs. Per Wk

Duties:

Specify the special skills you possess or courses/training you have completed, which are required for the job you are applying for:

Typing speed: net wpm Foreign Language Skills: Speak Read Write

PC Software Programs (Proficient in)

I certify that the information contained in this application is true and correct and that any falsification, misrepresentation or omission on this application is grounds for disqualification from the selection process and/or termination of employment, if discovered at any time in the future. I authorize any of the persons or organizations referenced in this application to give the City of Carson any and all information concerning my previous employment, education, or any other information covered by this application and release all such parties and the City of Carson from all liability for any damage that may result from furnishing such information. I authorize the City of Carson to request and receive such information.

I acknowledge that any offer of employment, or my acceptance of an employment offer, is contingent upon passing live scan, background check or other tests. I understand that this application and other documents that I may receive are not contracts of employment. I further understand that no representative of the City other than the City Manager or his/her designee has any authority to make an offer of employment.

Signature of Applicant Date

From (Mo/Yr) Previous Employer Supervisor: Name & Phone

To (Mo/Yr) Address - Number and Street City State ZipSalary

Monthly Hourly

Job Title Reason for Leaving Hrs. Per Wk

Duties:

From (Mo/Yr) Previous Employer Supervisor: Name & Phone

To (Mo/Yr) Address - Number and Street City State ZipSalary

Monthly

Hourly

Job Title Reason for Leaving Hrs. Per Wk

Duties:

CITY OF CARSONAPPLICANT INFORMATION RECORD

12797/14

The information shown on this form is considered confidential. It is excluded from public inspection, and is furnished only to Human Resources. It is used for recruitment monitoring purposes and is not circulated or filed with the application.

Last name:

Address:

Date:

Position Applied for: OCCUPATIONAL CATEGORY( Filled in by City) CODE

ETHNIC BACKGROUND In order to monitor our recruitment process to ensure equal opportunity for all applicants, the City requests the following:

RACE/ETHNIC CODE: (See Code Below)

I hereby declare that the information furnished on this form is true and correct to the best of my knowledge.

Applicant's Signature Date

First Name:

CODE RACE/ETHNIC CATEGORIES100 WHITE (Persons having origins in any of the original peoples of Europe, North Africa or the Middle East)101 European102 North African 103 Middle Eastern

200 BLACK (Persons having origins in any of the Black racial groups of Africa. Persons not of Hispanic origin)

300 HISPANIC (Persons of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish culture or origin regardless of race) 301 Mexican302 Puerto Rican 303 Cuban304 Central American305 South American

400 ASIAN/PACIFIC ISLANDER (Persons having origins in any of the original peoples of the Far East, Southeast Asian, the Indian Subcontinent, or the Pacific Islands)

401 Chinese402 East India - From India403 Japanese404 Korean405 Pakistani406 Filipino407 Samoan408 Vietnamese409 Other Asian

500 AMERICAN INDIAN/ ALASKAN NATIVE (Persons having origins in any of the original people of North America, and WHO MAINTAIN CULTURAL IDENTIFICATION THROUGH TRIBAL AFFILIATION OR COMMUNITY RECOGNITION)

501 American Indian502 Alaskan Native

Male Female AGE GROUP: Under 40 Over 40 GENDER:

RACE (Ethnic Background)

Middle Name:

How did you become aware of this employment opportunity? Mark all that are applicable: (Specify)

City Job Bulletin

City Web Site

City Job HOTLINE

Friend / Relative

Newspaper Ad

Publication Ad

Another City or Agency

Other Web Site