Contra
DATE RECEIVED
For Human Resources Use Only
Administrative Intern
Costa
Accepted
Rejected
Bid/Transfer
County
Deep Class Reassignment
Analyst
Date
Flexibly Staffed Promotion
EMPLOYMENT APPLICATION
Reason:
Educ.
License/Cert.
Student Worker
AN EQUAL OPPORTUNITY EMPLOYER
Exp.
Incomplete
Contra Costa County Human Resources
Temporary
Other
nd
651 Pine Street – 2
Floor
Martinez, California 94553-1292
Temporary Upgrade
POSITION APPLYING FOR:
PRINT EXACT JOB CLASSIFICATION TITLE
PLEASE TYPE OR PRINT IN INK
1.
Social Security Number – for Applicant/Employee Record Control (Voluntary)
2.
Name:
Last Name
First Name
Middle Name
3.
Address:
No.
Street
Apt. No.
City
State/Zip Code
(
)
(
)
(
)
4.
Phones:
Home/CRS/TTY
Work
Cell Phone
5.
E-mail Address:
Driver’s License:
State
Number
Expiration Date
6. After employment, can you submit verification of your legal right to work in the U.S.?
Yes
No
7.
Have you ever been rejected during a probationary period, forced to resign in lieu of termination, dismissed,
Yes
fired, terminated, or had an employment contract terminated from any position for performance or for
disciplinary reasons within the last ten (10) years?
No
_____________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________
8.
Are you fluent in any language other than English? If so, please specify:
9.
Veterans’ Points – In open examinations, Contra Costa County will add five percent (5%) to your earned examination
score if you pass the examination AND meet one of the following qualifications:
(1)
You have served continuously on active duty for more than 180 days and received an honorable discharge by
the final filing deadline for the examination; or
(2)
You are a disabled veteran.
To apply for points you MUST submit a copy of Form DD214 that indicates an honorable discharge or a general discharge
under honorable conditions before the final filing deadline. Written verification of disability from the Veteran’s Administration
is required for disabled veterans. Veterans’ points do not apply to promotional examinations.
Please mark (X) in the box if you are applying for Veterans’ Credit and have attached the proper documentation.
Verify (v)
OFFICE USE ONLY
10.
Are you currently a Contra Costa County employee?
Yes
No
If yes, enter Employee Number ____________
Merit System Title ___________
AK-1 (6/14)
EQUAL EMPLOYMENT OPPORTUNITY
To assist Contra Costa County in its commitment to Equal Employment Opportunity, applicants are asked to voluntarily provide the following information. To demonstrate that we meet equal
employment opportunity requirements, periodically we must report statistical information about applicants and employees to the State and Federal Governments. When reported, data will not identify
a specific individual. This questionnaire will be detached from the application prior to the examination, will be kept separate and confidential and will not be used in employment decisions.
Please answer all questions by placing an “X” in the appropriate box. (see reverse for definitions)
RACE/ETHNICITY: Only one box may be marked. Person of mixed races should classify according to the ethnic group with which they identify.
1
American Indian or Alaska Native (Not Hispanic or Latino)
N
A
M
E
2
Asian (Not Hispanic or Latino)
3
Black or African American (Not Hispanic or Latino)
POSITION APPLYING FOR
PRINT EXACT JOB CLASSIFICATION TITLE
4
Filipino (Not Hispanic or Latino)
5
Hispanic or Latino
AGE:
UNDER 40
40 OR OVER
6
Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino)
7
White (Not Hispanic or Latino)
GENDER:
MALE
FEMALE
8
Two or More Races (Not Hispanic or Latino)