CITY OF VALLEJO
EMPLOYMENT APPLICATION
HUMAN RESOURCES DEPARTMENT
555 SANTA CLARA STREET, Room 1
(707) 648-4364
www.ci.vallejo.ca.us
MAIL TO: P.O. BOX 3068
VALLEJO, CA 94590

AN EQUAL OPPORTUNITY EMPLOYER
Applications accepted only for open positions. Complete both sides using ink or typewriter. Answer all questions.

PERSONAL INFORMATION
*POSITION APPLIED FOR:
 *TYPE OF EMPLOYMENT DESIRED
         
*NAME (Last, First, Middle) 
 *Social Security #
*ADDRESS (Number, Street and Apartment No.)
 *Valid CA DRIVER LICENSE?
         License #
*(City, State and Zip Code)
 *If offered a position, can you provide documentation establishing your right to work in the United States?
    
*Home Phone
 Work Phone
 Email
CONVICTIONS:
Conviction of a crime is not necessarily a bar to employment. Each case is considered separately based on job requirements. Do not include: (a) any arrest or detention that did not result in conviction; (b) any conviction for which the record has been judicially ordered sealed, expunged, or statutorily eradicated; (c) any misdemeanor conviction for which probation has been successfully completed or otherwise discharged and the case has been judicially dismissed or (d) any arrest for which a pretrial or post-trial diversion program has been successfully completed.
*Have you ever been convicted of a crime other than a minor traffic violation?     
*Have you been arrested for and charged with a crime for which you are currently out on bail or on your own recognizance pending trial?      No
Complete this Portion if you answered “Yes” to either of the above questions.
Date (mm-dd-yyyy)
 City
 State
Court
 Charge of offense
 Action taken
If under 18, can you, after a job offer, submit a work permit?     
*Are you claiming Veteran’s Preference?
If Yes, Please attach a DD Form 214 (See job announcement for City of Vallejo’s policy regarding veteran points.) 		    
Were you ever terminated or forced to resign a position?
     
If “Yes” please fill in details. This answer will not necessarily result in disqualification.

EDUCATION AND TRAINING
*Name of High School
 Location
 *Did you graduate?
       
Name and location of college, business or trade school Dates Attended
From         To
Did you
graduate? 		Degree
Received		 Units
Sem./Qtr.		 Major
Subjects
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Licenses/Certifications: List licenses and/or certifications related to or required for this position.

EXPERIENCE
Dates employed
from: to: 		Employer
 Address
Hours Weekly
 Salary
 Your Title
 		Reasons for leaving
Supervisor's Name
 Duties
Number of Employees supervised
Employer's telephone number
Dates employed
from: to: 		Employer
 Address
Hours Weekly
 Salary
 Your Title
 		Reasons for leaving
Supervisor's Name
 Duties
Number of Employees supervised
Employer's telephone number
Dates employed
from: to: 		Employer
 Address
Hours Weekly
 Salary
 Your Title
 		Reasons for leaving
Supervisor's Name
 Duties
Number of Employees supervised
Employer's telephone number
Dates employed
from: to: 		Employer
 Address
Hours Weekly
 Salary
 Your Title
 		Reasons for leaving
Supervisor's Name
 Duties
Number of Employees supervised
Employer's telephone number
Dates employed
from: to: 		Employer
 Address
Hours Weekly
 Salary
 Your Title
 		Reasons for leaving
Supervisor's Name
 Duties
Number of Employees supervised
Employer's telephone number

POLICE OFFICER & FIRE FIGHTER APPLICANTS ONLY:
Will you, by the final filing date, have reached your 18th birthday? 		    

I CERTIFY THAT ALL STATEMENTS MADE IN THIS APPLICATION ARE TRUE AND COMPLETE AND SUBJECT TO VERIFICATION. I AUTHORIZE INVESTIGATION OF ALL STATEMENTS CONTAINED IN THIS APPLICATION AND HEREBY AUTHORIZE EMPLOYERS, SCHOOLS OR PERSONS NAMED IN THIS APPLICATION TO GIVE ANY INFORMATION REGARDING MY QUALIFICATIONS AND CHARACTER. I HEREBY RELEASE SAID EMPLOYERS, SCHOOLS, PERSONS AND THE CITY FROM ANY LIABILITY FOR DAMAGES FOR RECEIVING OR RELEASING INFORMATION. I AGREE AND UNDERSTAND THAT ANY MISSTATEMENT OR OMISSION OF MATERIAL FACT ON THIS APPLICATION WILL CAUSE FORFEITURE ON MY PART OF ALL RIGHTS TO BE CONSIDERED FOR EMPOYMENT WITH THE CITY AND MAY BE CAUSE FOR DISMISSAL IF ALREADY EMPLOYED. I FURTHER AGREE TO BE FINGERPRINTED, TO SUBMIT TO A JOB-RELATED MEDICAL EXAMINATION, INCLUDING DRUG SCREENING, AND FURNISH SUCH PROOF OF MEETING THE CONDITIONS OF EMPLOYMENT AS MAY BE REQUIRED. (If application is submitted online or by Fax, we will require an original signature at the time of exam.)
Applicant's Signature

DISABLED APPLICANTS: THE HUMAN RESOURCES DEPARTMENT WILL MAKE REASONABLE ACCOMMODATION IN THE EXAM PROCESS TO ACCOMMODATE DISABLED APPLICANTS. IF YOU HAVE A DISABILITY FOR WHICH YOU REQUIRE ACCOMMODATION, PLEASE CALL THE HUMAN RESOURCES DEPARTMENT AT (707) 649-4852 NO LATER THAN FIVE (5) DAYS BEFORE THE TEST DATE.

VOLUNTARY APPLICANT INFORMATION
In order to comply with federal guidelines, we request that you voluntarily provide the following information to be used for research and evaluation purposes. This information will be separated from your application upon receipt by the Human Resources Department, and is not considered in the hiring process.
To assist us in outreach efforts, please indicate how you found out about this job.













please specify.
Sex     
Racial/ethnic category with which you most closely identify according to the ethnic definitions listed below.
(Not of Hispanic Origin) All persons having origins in any of the original peoples of Europe, North Africa, or the Middle East.
(Not of Hispanic Origin) All persons having origins in any of the Black racial groups.
All persons of Mexican, Puerto Rican, Central or South American or other Spanish culture or origin, regardless of race.
ASIAN/ 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. This area includes, for example, China, Japan, Korea, and Samoa.
All persons having origins in any of the original peoples of the Philippine Islands.
All persons having origins in any of the original peoples of North America, and who maintain cultural identification through tribal affiliation or community recognition. Please identify with which tribe you are affiliated.

OTHER Persons belonging to groups whose origin is NOT listed above. Please specify group: