KLAMATH 9-1-1 COMMUNICATIONS DISTRICT

EMPLOYMENT APPLICATION

Klamath 9-1-1 Communications District is an Equal Opportunity Employer. We do not use personal information in our application process and are dedicated to accepting the person who is best suited for our positions without any knowledge or consideration to any individual’s membership in any protected class. Any personal information found on this application or any supporting documentation will be removed as soon as it is discovered.

PLEASE TYPE OR PRINT: ANY ILLEGIBLE OR INCOMPLETE APPLICATION WILL NOT BE CONSIDERED

Position Applying For:__________________

Name:______

Last First Middle

Other names used:______

Address:______

Street Mailing City State Zip

How Long At This Address: ______If Less Than 3 Years, List Previous Address and Length:

______

Telephone:______

Daytime Evening

Have you ever applied or worked for the District before? YES______NO ______WHEN ______

Social Security Number: ______Driver’s License Number ______State____

Education and Training

High School Name:______

Address:______City:______State:______

Year of Graduation:______with Diploma ______GED ______

College Name:______

Address: ______City:______State:______

Degree?______Major ______Credits______

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List All Pertinent Telecommunication Training:

Course and Year Attended:______

Course and Year Attended:______

Course and Year Attended:______

Course and Year Attended:______

Employment History: Beginning with your current or most recent employer working backwards

1. Employer Name:______

Address:______City:______State:______

Contact Phone number:______Supervisor Name:______

Start Date:______/______/______End Date:______/______/______

Position held:______

Duties:______

______

______

Reason for Leaving (even if still employed, why are you seeking other employment)?______

______

2. Employer Name:______

Address:______City:______State:______

Start Date:______/______/______End Date:______/______/______

Contact Phone Number:______Supervisor Name:______

Positionheld:______

Duties:______

______

______

Reason for Leaving (even if still employed, why are you seeking other employment)?______

______

3. Employer Name:______

Address:______City:______State:______

Start Date:______/______/______End Date:______/______/______

Contact Phone Number:______Supervisor Name:______

Position held:______

Duties:______

______

______

Reason for Leaving (even if still employed, why are you seeking other employment)?______

______

4. Employer Name:______

Address:______City:______State:______

Start Date:______/______/______End Date:______/______/______

Contact Phone Number:______Supervisor Name:______

Position held:______

Duties:______

______

______

Reason for Leaving (even if still employed, why are you seeking other employment)?______

______

Attach a separate sheet if necessary to continue employment history.

Attach a letter of interest describing your attributes and deficiency; both of which not only make you qualified for the position but will allow you to be successful in this position.

Attach resume, any reference letters and copies of training certificates for consideration.

References

List three professional references:

Name:______Relationship:______

Complete Physical and Mailing Address:______

______Contact Phone Number:______

Name:______Relationship:______

Complete Physical and Mailing Address:______

______Contact Phone Number:______

Name:______Relationship:______

Complete Physical and Mailing Address:______

______Contact Phone Number:______

List three personal references:

Name:______Relationship:______

Complete Physical and Mailing Address:______

______Contact Phone Number:______

Name:______Relationship:______

Complete Physical and Mailing Address:______

______Contact Phone Number:______

Name:______Relationship:______

Complete Physical and Mailing Address:______

______Contact Phone Number:______

CERTIFICATION AND AGREEMENT

I certify all information given on this application and any supporting information is true and complete and I authorize a complete investigation. I agree that if accepted, I may be discharged if the District, at any time learns of any falsification or material omission in the information I have provided and if discovered prior to acceptance, I would be ineligible for consideration for not only this position but future positions as well. I authorize Klamath 9-1-1 Communication District to contact all former and current employer references listed and all educational institutions. All references are authorized to release to the District all information requested which they might have about me. I hereby release all references and the District from any liability, which might be claimed because of information provided by such references.

I agree that, if accepted, I will follow all District policies, rules, procedures and all other directions. I understand that the District is committed to promoting safety and high standards of performance, productivity and reliability. In order to achieve this, all finalists may be subjected to a drug test prior to being hired to assure the applicant does not currently have narcotics, sedatives, stimulants, and other controlled substances in their body. I further understand that if I am selected as a finalist with the District, a criminal history investigation will be conducted.

______

Applicant’s Signature Date SSN #

NOTE: No consideration will be given to any applicant that does not sign the above statement

BACKGROUND INVESTIGATION

Are you willing to submit to a thorough criminal and personal background investigation?

YES _____ NO _____

Is your record clear of adult felony and misdemeanor convictions? YES _____ NO _____

Do you have any criminal history? YES _____ NO_____

If so, explain:______

Are you willing to submit to a drug and alcohol screening test?YES _____ NO _____

Are you willing to submit to a physical examination?YES _____ NO _____

Revised 4/10/08

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