City of Culver City

/ APPLICATION FOR EMPLOYMENT
Personnel Department
7100 Garfield Boulevard
Bell Gardens, CA90201
(562) 806-7700 Main line
An Equal Opportunity/Affirmative Action Employer / Date and Time Stamp
(Human Resources Use Only)
POSITION APPLIED FOR: / Job ID#
PERSONAL / CONTACT INFORMATION
LAST NAME / FIRST NAME / MIDDLE INITIAL / HOME TELEPHONE NUMBER
ADDRESS: NUMBER STREET APT # / MESSAGE TELEPHONE NUMBER
CITY / STATE / ZIP CODE / E-MAIL ADDRESS
If you are related to a Bell GardensCity employee, please provide the following information:
Employee Name / Relationship / Department / Their Job Title
Are you willing to work: / ** For Positions that Require Driving **
Full Time?
Part Time?
Temporary?
Seasonal?
On-call? / no yes
no yes
no yes
no yes
no yes / Days?
Nights?
Weekends?
Holidays?
Shift Work? / no yes
no yes
no yes
no yes
no yes / Do you have a valid California driver’s license? no yes
Driver License Information
State / Number
Class / Endorsement / Expiration Date (xx/xx/xxxx)
/ /
Public Employees Retirement System (PERS) Status / ** Police Officer / Recruit Applicants only **
Are you currently a member of PERS?no yes
Have you ever been a member of PERS?no yes / Are you a U.S. citizen no yes
Are you at least 20 ½ years old no yes
EDUCATION AND TRAINING
Did you graduate from high school?
Did you earn a GED? / no yes
no yes / Name of High School (or Institution that provided GED)
Circle Highest Grade Completed
1 2 3 4 5 6 7 8 9 10 11 12 / City and State
*** Must attach copies of all degrees and certificates received at time of application ***
Names of Colleges, Universities and/or Military Academies attended / Location
(City, State) / Number of Units
Semester Quarter / Major / Emphasis / Graduated? / Degree / Certificate Received
1) / no yes
2) / no yes
3) / no yes
Trade or Vocational
Schools attended / Location / Credit Type
Units Hours / Area of Study/Trade / Degree / Certificate
1) / no yes
2) / no yes
FOR OFFICE USE ONLY
Screening Date(s) / Reviewed by (HR) / Reviewed by (Dept) / Possess All Required License(s)
No Yes / Screening Applicant Disposition
NQ DEF MSR MMR AMQ
COMMENTS
- READ CAREFULLY BEFORE BEGINNING THIS SECTION -

Read the experience requirements in the job bulletin before completing this section.
Begin with your most recent job. List different positions with the same employer separately.
Account for all time within the last 10 years, including military, self-employment, volunteer and any time you were not employed for any reason. Employment and personal references may be verified.
List all periods of employment with the City of Bell Gardens, regardless of when they occurred.
Fill out completely. Do not leave any blanks. Attach an additional sheet if you need more space.
Incomplete applications may not receive full consideration.
Resumes are NOT accepted in place of any part of this application. However, you may include a résumé in addition to this application for consideration.
May we contact your present employer? Yes No

EXPERIENCE
FROM / TO / Title of Your Position: / Number of hours worked per week: / Number of Employees you supervised:
Month / Year / Month / Year
Salary
$ / Hourly
Monthly / Weekly
Annually / Duties of Your Position:
Company or
Employer:
Street
Address:
City, State and
Zip:
Phone
Number:
Supervisor’s
Name:
Supervisor’s
Title: / Reason for leaving or wanting
to leave if presently employed:
FROM / TO / Title of Your Position: / Number of Hours worked per week: / Number of Employees you supervised:
Month / Year / Month / Year
Salary
$ / Hourly
Monthly / Weekly
Annually / Duties of Your Position:
Company or
Employer:
Street
Address:
City, State
And Zip:
Phone
Number:
Supervisor’s
Name:
Supervisor’s
Title: / Reason for leaving:
FROM / TO / Title of Your Position: / Number of Hours worked per week: / Number of Employees you supervised:
Month / Year / Month / Year
Salary
$ / Hourly
Monthly / Weekly
Annually / Duties of Your Position:
Company or
Employer:
Street
Address:
City, State
And Zip:
Phone
Number:
Supervisor’s
Name:
Supervisor’s
Title: / Reason for leaving:
JOB ID# / POSITION APPLIED FOR: / APPLICANT NAME (print):
EXPERIENCE (Cont’d): You may attach a copy of this page to reflect additional information.
FROM / TO / Title of Your Position: / Number of Hours worked per week: / Number of Employees you supervised:
Month / Year / Month / Year
Salary
$ / Hourly
Monthly / Weekly
Annually / Duties of Your Position
Company or
Employer:
Street
Address:
City, State
And Zip:
Phone
Number:
Supervisor’s
Name:
Supervisor’s
Title: / Reason for leaving:
FROM / TO / Title of Your Position: / Number of Hours worked per week: / Number of Employees you supervised:
Month / Year / Month / Year
Salary
$ / Hourly
Monthly / Weekly
Annually
Company or
Employer:
Street
Address:
City, State
And Zip:
Phone
Number:
Supervisor’s
Name:
Supervisor’s
Title: / Reason for leaving:
FROM / TO / Title of Your Position: / Number of Hours worked per week: / Number of Employees you supervised:
Month / Year / Month / Year
Salary
$ / Hourly
Monthly / Weekly
Annually / Duties of Your Position
Company or
Employer:
Street
Address:
City, State
And Zip:
Phone
Number:
Supervisor’s
Name:
Supervisor’s
Title: / Reason for leaving:
Periods Of Unemployment
From: / To: / Reason:
From: / To: / Reason:
From: / To: / Reason:
From: / To: / Reason:
JOB ID# / POSITION APPLIED FOR: / APPLICANT NAME (print):
CONVICTION RECORD (required from all applicants)
Acceptance of the application of a person convicted of a crime depends upon the nature of the conviction and the conduct of the applicant subsequent to the offense. Convictions will be evaluated on a job related basis and will not automatically disqualify someone from further consideration. Answer this section truthfully, including both minor and serious offenses of which you were convicted. Any omissions may be grounds for rejection of the application, removal from the eligible list or dismissal from position.
Have you ever been convicted of a breach or violation of any ordinance or law, other than a minor traffic violation?
No Yes / If yes, provide the information requested below for each conviction (continuing on back of page if necessary). Be specific, give name and code number of offense, not simply misdemeanor or felony.
OFFENSE # / NAME / OFFENSE # / NAME / OFFENSE # / NAME
DATE / DATE / DATE
LOCATION / LOCATION / LOCATION
SENTENCE/FINE / SENTENCE/FINE / SENTENCE/FINE
CONDITIONS OF EMPLOYMENT, IF SELECTED
Upon a conditional offer of employment, a pre-placement medical evaluation, drug/alcohol screening (select positions), and California Department of Justice (DOJ) Live Scan fingerprinting must be completed with acceptable results.Upon hire, employee is subject to further reporting from DOJ via subsequent arrest notification. All new employees must present proof of U.S. Citizenship or the legal right to remain and work in the U.S.
CERTIFICATION AND WAIVER
Read carefully before signing
I have read and understand the above information pertaining to this application. I hereby certify that all statements made in this application are true and complete and that misstatement of material fact will be subject to disqualification or dismissal. Furthermore, I give my consent to contact current and former employers, references and physician(s)and fully release same from any liability regarding information provided in connection with this application or subsequent employment.
SIGNATURE: / DATE:
City of Bell Gardens
An Equal Opportunity/Affirmative Action Employer
JOB ID# / POSITION APPLIED FOR: / APPLICANT NAME (print):
VOLUNTARY STATISTICAL INFORMATION
This information is requested to assist the City in complying with Federal and State reporting requirements. The data you provide will be detached from your application and used only for research and statistical purposes. All information in this section is confidential; no one connected with the hiring process will have access to this information.
DEMOGRAPHICS / RACE / ETHNICITY
GENDER: Male
Female
AGE GROUP: Under 21
21 - 39
40 and over / Check only one (primary) race / ethnicity
Native American / Alaskan Native
Asian Or Pacific Islander
Black, African American
Hispanic
White, Caucasian / If multi-racial, please check all that apply
Native American / Alaskan Native
Asian Or Pacific Islander
Black, African American
Hispanic
White, Caucasian
RACE / ETHINICITY DEFINITIONS
Definitions for Race/Ethnicity as defined by the United States Equal Employment Opportunity Commission (EEOC). This information is used for reporting purposes only, as required by the EEOC.
AMERICAN NATIVE/ ALASKAN NATIVE / All persons having origins in any of the original peoples of North America, and who maintain cultural identification through tribal affiliation or community recognition.
ASIAN OR PACIFIC ISLANDER / All persons having origins in any of the original peoples of the Far East, Southeast Asia, the Indian subcontinent, or the Pacific Islands. (e.g., China, Japan, Korea, Samoa and the Philippine Islands)
BLACK, AFRICAN AMERICAN / (Not of Hispanic origin) All persons having origins in any of the racial groups of Africa.
HISPANIC / All persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of race.
WHITE, CAUCASIAN / (Not of Hispanic origin) All persons having origins in the original peoples of Europe, North Africa or the Middle East.
I FIRST LEARNED ABOUT THIS JOB OPENING THROUGH……(check all that apply)
Bell Gardens website
Job posting at Bell Gardens City Hall
Received Bell Gardens interest card in mail
Job Posting at other government agency
Friend or relative
City employee: ______
Other: ______/ Job Fair (specify location/event name):
College/university job posting (school):
CareerCenter (organization or school):
Internet job posting (specify site):
Newspaper / Magazine ad (specify):
Newsletter ad (specify organization):
Business/Networking Group:
E-mail blast (specify sender/group): / ______
______
______
______
______
______
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