Date * MM DD YYYY Last Name * First Name * Middle Present Address Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Permanent Address (if different from present address) Address Address 1 Address 2 City State/Province Zip/Postal Code Country Home Phone * (###) ### #### Cell Phone (###) ### #### Email Employment Desired Are you applying for: Regular full time work? ... * Yes No Regular Part-time work? * Yes No Temporary work? * Yes No Would you be available to work overtime, if necessary? * Yes No Office Location: Pleasanton Gilroy Rocklin If hired, on what date can you start work? * MM DD YYYY Salary desired: $ Personal Information Have you ever applied to or worked for RJA before? * Yes No If yes, when? MM DD YYYY Do you have any friends or relatives working for RJA? * Yes No If yes, name(s) & relationship If hired, would you have a reliable means of transportation to and from work? * Yes No Are you at least 18 years old? * (If under 18, hire is subject to verification of minimum legal age.) Yes No If hired, can you present evidence of your U.S. citizenship or proof of your legal right to live and work in this country? Yes No Are you able to perform the essential functions of the job for which you are applying, either with or without reasonable accommodation? * Yes No If no, describe the functions that cannot be performed. (Note: We comply with the ADA and consider reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. Hire may be subject to passing a medical examination, and to skill and agility tests.) Are you currently employed? * Yes No If so, may we contact your current employer? Yes No Education, Training and Experience High School Name and Address * No. of years Completed * Did You Graduate? Yes No Degree or Diploma * College/University Name and Address * No. of years Completed * Did You Graduate? Yes No Degree or Diploma Vocational/ Business Name and Address * No. of years Completed Did You Graduate? Yes No Degree or Diploma Do you have any other experience, training, qualifications or skills which you feel make you especially suited for work at RJA? If so, please explain. * Answer the following questions if you are applying for a professional position Are you licensed//registered/certified for the job applied for? * Yes No Issuing State * Name of license/registration/certificate License/registration/cert. number Has your license/registration/certification ever been revoked or suspended? Yes No If yes, state reason(s), date of revocation or suspension and date of reinstatement Employment History List below your 3 most recent employers starting with your current employer if applicable. Account for any periods of unemployment. You must complete this section even if attaching a resume. Name of Employer Phone Number (###) ### #### Type of Business Your Supervisor’s Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Dates of Employment: From MM DD YYYY To: MM DD YYYY Your Position and Duties Reason for Leaving Current Employer? Yes No May we contact this employer for a reference? Yes No Name of Employer Phone Number (###) ### #### Type of Business Your Supervisor’s Name No. and Street City State Zip Code Dates of Employment: From MM DD YYYY To MM DD YYYY Your Position and Duties Reason for Leaving May we contact this employer for a reference? . Yes No Name of Employer Phone Number (###) ### #### Type of Business Your Supervisor’s Name No. and Street City State Zip Code Dates of Employment: From MM DD YYYY To MM DD YYYY Your Position and Duties Reason for Leaving May we contact this employer for a reference? Yes No References List below three persons not related to you who have knowledge of your work performance within the last three years. Name No. and Street City State Zip Code Occupation Number of Years Acquainted Phone Number Email Address Name No. and Street City State Zip Code Occupation Number of Years Acquainted Phone Number (###) ### #### Email Address Name No. and Street City State Zip Code Occupation Number of Years Acquainted Phone Number (###) ### #### Email Address Please Read Carefully, Initial Each Paragraph and Sign Below * I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of material fact on this application or on any document used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery. * I hereby authorize the company to thoroughly investigate my references, work record, education and other matters related to my suitability for employment and, further, authorize the references I have listed to disclose to the company any and all letters, reports and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release the company, my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure. * I hereby agree to submit to binding arbitration all disputes and claims arising out of the submission of this application. I further agree, in the event that I am hired by the company, that all disputes that cannot be resolved by informal internal resolution which might arise out of my employment with the company, whether during or after that employment, will be submitted to binding arbitration. I agree that such arbitration shall be conducted under the rules of the American Arbitration Association. This application contains the entire agreement between the parties with regard to dispute resolution, and there are no other agreements as to dispute resolution, either oral or written. * I understand that nothing contained in the application, or conveyed during any interview which may be granted or during my employment, if hired, is intended to create an employment contract between me and the company. In addition, I understand and agree that if I am employed, my employment is for no definite or determinable period and may be terminated at any time, with or without prior notice, at the option of either myself or the company, and that no promises or representations contrary to the foregoing are binding on the company unless made in writing and signed by me and the company’s designated representative. Date * MM DD YYYY Applicant’s Signature * Upload your cover letter & resume as a pdf * FileField; MaxSize=5000KB; Multiple; addText=Upload_Resume Thank you! Field Survey Party Chief An Equal Opportunity Employer
