Fillable Employment Application - Contra Costa County printable pdf download

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

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

Social Security Number – for Applicant/Employee Record Control (Voluntary)

Name:

Last Name

First Name

Middle Name

Address:

No.

Street

Apt. No.

City

State/Zip Code

(

)

(

)

(

)

Phones:

Home/CRS/TTY

Work

Cell Phone

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

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?

_____________________________________________________________________________________________________________________________________

Are you fluent in any language other than English? If so, please specify:

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

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.

American Indian or Alaska Native (Not Hispanic or Latino)

Asian (Not Hispanic or Latino)

Black or African American (Not Hispanic or Latino)

POSITION APPLYING FOR

PRINT EXACT JOB CLASSIFICATION TITLE

Filipino (Not Hispanic or Latino)

Hispanic or Latino

AGE:

UNDER 40

40 OR OVER