Last Name : *	First Name : *			Middle Name :
Street Address : *	City : *		State : *
Zip Code : *	Phone Number : *	(ex : 123-123-1234)
Email :		Phone(Message) : (ex: 123-123-1234)

Are you under the age of 18 years? If under 18, you will be required to furnish a work permit.	YesNo
Do you have relatives currently employed by the District? This information is used to prevent placement that may create conflicts of interest.	YesNo
If yes, indicate the employee's name and relationship
Have you ever worked for the District?	YesNo
If yes, when?
Have you been a member of CalPERS?	YesNo
Have you ever been convicted of a felony?	YesNo
Convictions will not neccessarily disqualify you from employment. If yes, describe conditions:

Please select this checkbox if you have no prior job experience.

Employment Experience

Please give a complete full or part-time employment record. Please begin with your Current employer.

Current Employer :*

Start Date :

Name and Title of Supervisor :

End Date :

Present

Address :

Phone Number :
(Include Area Number)

(ex: 123-123-1234)

Job Title :

Hourly Wage :

Job Duties :

Reason of Leaving :

May we contact this employer for a reference?

YesNo

Previous Employer :

Start Date :

Name and Title of Supervisor :

End Date :

Address :

Phone Number :
(Include Area Number)

(ex: 123-123-1234)

Job Title :

Hourly Wage :

Job Duties :

Reason of Leaving :

May we contact this employer for a reference?

YesNo

Previous Employer :

Start Date :

Name and Title of Supervisor :

End Date :

Address :

Phone Number :
(Include Area Number)

(ex: 123-123-1234)

Job Title :

Hourly Wage :

Job Duties :

Reason of Leaving :

May we contact this employer for a reference?

YesNo

For reference checking purposes, list other names under which you have worked or attended school:

Education and Training

Did you graduate from high school?	YesNo
If you did not graduate from high school, do you possess a GED or equivalent?	YesNo

College, University, Technical or Vocational Education

Name	City/State	Graduate?	Degree or Certificate Received
		YesNo
		YesNo
		YesNo
		YesNo

Professional License or Certification

Title		Number
Issued By		Expiration Date
Title		Number
Issued By		Expiration Date
Title		Number
Issued By		Expiration Date

Special Skills and Qualification

Summarize special job related skills and qualifications acquired from employment or other experience, Include equipment operated and licensed for, computer skills, typing speed, etc.

References

Give the name, address and telephone number of three references that are not related to you and are not previous employers

Applicant's Certification

I certify that the information contained in this employment application and any related documents I am submitting is true and complete and understand that falsification of this information is grounds for refusal to hire, or if hired, termination of employment.

I understand that an offer of employment is contingent on successful completion of a background check and physical examination, at the expense of Jurupa Community Services District, to determine if I am physically able to perform the essential job duties of the position I am applying for, with or without reasonable accommodation. I further understand that the physical examination includes alcohol and drug testing, and I agree to sign a release authorizing the health professional performing the drug screening to release the result of the drug screening to Jurupa Community Services District. I further understand that an effect of employment may also be contingent on my supplying the District with an original, current (no more than two weeks prior to the date of the conditional offer), acceptable Driver License Report from the DMV, and a valid California Driver License.

If accepted for employment, I understand I must submit verification of my legal right to work in the United States.

I understand that this Certification is not an offer of employment by Jurupa Community Services District or a contract for employment with the District. I further understand that Jurupa Community Services District operates under an At Will Employment Policy for probationary and temporary employees and this Certification does not alter or affect that policy in any manner whatsoever.

I hereby agree with and consent to all of the foregoing in consideration of Jurupa Community Services District considering me for employment.

Please read and accept the Applicant Certification
Online Applications once submitted cannot be modified for six months

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