Application for Employment by 5sk81od

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									                                                                              The City and Borough of Juneau
                                                                                                    Application for Employment
                                                                                        Human Resources & Risk Management Division
                                                                                       155 South Seward Street, Juneau, Alaska 99801
      PRINT IN DARK INK OR TYPE. A separate application must be submitted for each job position for which you apply.
      You may make copies of this application and enter different job titles and job announcement numbers but your original
      signature is required on each application submitted. Information on resumes will not be accepted in lieu of a full and
      complete response to each area of this application. If you are selected for an interview or further examination, you must
      be able to provide TWO different documents establishing your identification to determine eligibility for employment
      pursuant to federal law. (For a list of acceptable forms of identification, please see the U.S. Department of Justice
      Immigration and Naturalization service List of Acceptable Documents form contained in this application.)
 1.    Job Announcement –
       Position Title                                                                                  2. Job Announcement #:

                                                                   Personal Data
3. Name:                                                                                                Date:
                Last                                       First                            M.I.

4. Other names under which you have worked:

5. Mailing Address:
                                                 Street Address                             Apartment/Unit #



                City                                                                        State                          ZIP Code
6. Telephone Numbers:        (       )                                                 (     )                         (          )
                              Home Phone                                                             Work and/or Message Phone
7. Social Security No.:

8. Are you a citizen of the United States or an alien authorized to work in the United States? (Proof of citizenship
or immigration status will be required upon employment.)                                                                    YES       NO


9. Are you a resident of the City and Borough of Juneau?                                                                    YES       NO

10. Are you 18 years of age or older?                                                                                       YES       NO
11. If you are less than 18 years old, what is your birth
date?

12. Have you been convicted of a misdemeanor within the past five years?                                                    YES       NO

If yes, describe in full.



Have you ever been convicted of a felony?                                                                                   YES       NO
If yes, describe in full. (The existence of a criminal record is not an absolute bar
to employment with the City and Borough of Juneau.)




13. Are you currently or have you ever been employed by CBJ?                                                               YES        NO
      (City/Borough employees cannot hold more than one position concurrently without prior approval of the Human Resources Director.)

If yes, Position Title and dates of employment:

14. Relatives by blood, marriage, or domestic partnership employed by the City and Borough of Juneau:
                    Name                                 Relationship                                 Department




                                  THE CITY AND BOROUGH OF JUNEAU IS AN EQUAL OPPORTUNITY EMPLOYER.
                                                    Education and Experience Data
      The scheduling of applicant interviews and examinations is based upon the data furnished in this application, which includes your
     Educational background and Employment History. Incomplete applications may result in disqualification from further consideration.
 EDUCATIONAL
 BACKGROUND                            Grade School             High School        College                       Post Graduate
 15. Check highest level          1       2       3     4         9       10       13        14        1          2         JD
 completed:                       5       6       7     8         11      12       15        16        MA         MS        PhD
 16. Name and Address of
 last high school:

                                                                                               Did you graduate?               YES        NO

 17. High School Equivalency Certificate (GED):      State:                        Cert Number:                  Date:
 18. List number of college quarter or semester hours completed with a passing grade as recorded on your transcriptions. Furnish a copy
 of college transcripts if requested.
                                                        Dates Attended       Hrs. Completed    Degree(s)
  Type of School             (Name, City, and State)   From         To        Qtr.     Sem.    Received                  Major

 College:

 College:

 Graduate Study:

Correspondence Study:

                                                           Dates Attended                              Courses Completed

 Business:

 Technical:

 Military School(s):
 19. Subjects which may be related to position for which you are applying:




                                                          Special Qualifications
 20.   Please list any special qualifications that may be required or useful in this position. This would include licenses or certifications.
                 Type                                    Issued By                                           Expiration Date




 21. Driver’s License Number                                State of Issuance:                              Expiration Date:

 Alaska Commercial Driver’s License Number:                                             Expiration Date:

 22. Typing:                            words per minute         and/or      10-key:                            strokes per minute

 23. Word processing, spreadsheets and database programs you have used:



 24. List types of electronic and mechanical equipment or machinery that you are qualified to:
                                           Operate    AND / OR      Repair




Page 2 of 6
                                                       Employment History
    25. Dates of Employment – month & year     Employer Name:
    From:                To:                    Employer Phone Number:
    Starting                                               Employer Address:
    Salary:     $                        Per               (street, city & state)
    Ending
    Salary:     $                        Per               Your Last Job Title:
    Hours Per Week                      Supervisor’s Name:                                   Supervisor’s Title
    No. Supervised:                                             May we contact this employer?     YES                      NO
    Duties:




    Reason for leaving:

    26. Dates of Employment – month & year       Employer Name:
    From:                To:                     Employer Phone Number:
    Starting                                             Employer Address:
    Salary:     $                  Per                     (street, city & state)
    Ending
    Salary:      $                Per                      Your Last Job Title:
    Hours Per Week                             Supervisor’s Name:                             Supervisor’s Title
    No. Supervised:                                         May we contact this employer?           YES                   NO
    Duties:




    Reason for leaving:

    27. Dates of Employment – month & year     Employer Name:
    From:                To:                   Employer Phone Number:
    Starting                                            Employer Address:
    Salary:     $                        Per            (street, city & state)
    Ending
    Salary:     $                        Per            Your Last Job Title:
    Hours Per Week                     Supervisor’s Name:                                  Supervisor’s Title
    No. Supervised:                                           May we contact this employer?     YES                        NO
    Duties:




    Reason for leaving:

    28. Dates of Employment – month & year       Employer Name:
    From:                To                      Employer Phone Number:
    Starting                                                Employer Address:
    Salary:     $                  Per                         (street, city & state)
    Ending
    Salary:      $                Per                         Your Last Job Title:
    Hours Per Week                               Supervisor’s Name:                                 Supervisor’s Title
    No. Supervised:                                              May we contact this employer?         YES                 NO
    Duties:




    Reason for leaving:




Page 3 of 6                                                                             Form: CBJ P001 rev: 09/06; 01/07; 05/08, 02/09, 04/09
                                                                        Other

     36. For which of the following types of positions are your available?         Full-time        Temporary          Seasonal          Part-time

     37. How soon would you be able to report for work after being notified that you had been hired?

     38. Comments:




                                                             Veteran’s Information
     Are you a Veteran of the military service?            Yes                No           From:                          To:

     Rank at Discharge:                                               Type of Discharge:




                            CERTIFICATE OF APPLICANT AND AUTHORIZATION TO VERIFY INFORMATION

                                         IMPORTANT: Please read before signing this application.

     I HEREBY CERTIFY that all of the information made on, or in connection with, this application is true and complete to the best of
     my knowledge and belief, and that I have not knowingly withheld any fact or circumstance. I understand that any
     misrepresentation or concealment of material fact will be sufficient grounds for rejection of application, removal from eligible
     lists or discharge from employment. I understand that consideration for employment in this position is contingent upon the
     results of a reference and/or background check. I therefore authorize the City and Borough of Juneau to investigate all
     statements made on my application for employment, and to discuss the results of its investigations with those responsible for
     hiring. I further authorize the City and Borough of Juneau to contact my former employers and any persons to respond to
     questions pertaining to information on this application. Further, I release from liability such former employers or other persons
     providing information to the City and Borough of Juneau. I understand that the benefits, rules and policies of the City and
     Borough of Juneau may be changed, modified, eliminated or added to at any time at the City and Borough of Juneau’s sole
     discretion and without prior notice.



     Signature:                                                                                              Date:

     Print Name:

                    Please check your application to be sure you have filled it out completely.
     Read the application requirements on the Job Announcement to be sure you are including any additional
                                               material requested
Where did you FIRST learn about this job?


a.         Job Service                                                       b.     City and Borough Employee
c.         Posted Job Announcement at:                                       d.     TV Scanner Channel 4
e.         Newspaper:                                                        f.     Internet Site: www.

g.         Professional Publication:                                         h.     Job Fair:

i.         Friend                                                            j.     Other - please provide details:




Page 4 of 6                                                                                        Form: CBJ P001 rev: 09/06; 01/07; 05/08, 02/09, 04/09
Job Announcement No.:                                                      Social Security Number:



Job Title:                                                                                      Date



                                                           City and Borough of Juneau
                                                        Equal Employment Opportunity Data
CBJP001

                                                                   TO ALL APPLICANTS

The information requested on this page is being gathered by the Human Resources & Risk Management Division for CBJ’s
Affirmative Action Program and to fulfill federal Equal Employment Opportunity reporting requirements. Your responses are
strictly voluntary, but we urge you to complete all items. Failure to provide this information will not subject you to adverse
effects. This page is detached from your application before the application is forwarded to the hiring department.
Date of Birth:

                                                        Racial/Ethnic/Gender Data
                                                             Definitions of Racial/Ethnic Groups

The racial/ethnic groups for CBJ affirmative action programs and federal reporting purposes are defined as follows:

Hispanic or Latino:                                                A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish
                                                                   culture or origin regardless of race.

White (Not Hispanic or Latino):                                    A person having origins in any of the original peoples of Europe, the Middle East or North
                                                                   Africa.

Black or African American (Not Hispanic or Latino):                A person having origins in any of the Black racial groups of Africa.

Native Hawaiian or Other Pacific Islander (Not Hispanic or         A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific
Latino):                                                           Islands.

Asian (Not Hispanic or Latino):                                    A person having origins in any of the original peoples of the Far East, Southeast Asia, or
                                                                   the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea,
                                                                   Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

American Indian or Alaska Native (Not Hispanic or Latino):         American Indian: A person having origins in any of the original peoples of North and
                                                                   South America (not including Alaska; including Central America), and who maintain tribal
                                                                   affiliation or community attachment.
                                                                   Alaska Native: A person having origins in any of the original peoples of Alaska, and who
                                                                   maintains cultural identification through tribal affiliation or community recognition.
                                                                   Alaskan Native may include any person of Yup'ik, Inupiat, Aleut, Athabascan, Tlingit,
                                                                   Haida or Tsimshian origin.

Two or More Races (Not Hispanic or Latino):                        All persons who identify with more than one of the above five races.


Please check one box:
                                                                                       Female                  Male
Hispanic or Latino:                                                                          I                        D

White (Not Hispanic or Latino):                                                                  G                    B

Black or African-American (Not Hispanic or Latino)                                               H                    C

Native Hawaiian or other Pacific Islander (Not Hispanic or Latino):                              L                    M

Asian (Not Hispanic or Latino):                                                                  J                    E

American Indian or Alaska Native (Not Hispanic or Latino):                                       K                    F

Two or more races (Not Hispanic or Latino):                                                      N                    O

Page 5 of 6                                                                                             Form: CBJ P001 rev: 09/06; 01/07; 05/08, 02/09, 04/09
                                              U.S. Department of Justice
                                         Immigration and Naturalization Service

                                           Employment Eligibility Verification
                                             List of Acceptable Documents


              LIST A                                      LIST B                                               LIST C

  Documents that Establish Both     OR     Documents that Establish Identity          AND           Documents that Establish
    Identity and Employment                                                                          Employment Eligibility
            Eligibility

                                           If you are providing a document from                   If you are providing a document
                                           List B, you will also need to provide a               from List C, you will also need to
                                                    document from List C.                         provide a document from List B.


1. U.S. Passport or U.S. Passport          1. Driver’s license or ID card                      1. Social Security Account
   Card                                       issued by a state or outlying                       Number card other than one
2. Permanent Resident Card or                 possession of the United States                     that specifies on the face
   Alien Registration Receipt                 provided it contains a                              that the issuance of the
   Card (Form I-1551)                         photograph or information                           card does not authorize
3. Foreign passport that                      such as name, date of birth,                        employment in the United
   contains a temporary I-551                 sex, height, eye color and                          States
   stamp or temporary I-551                   address.                                         2. Certification of Birth Abroad
   printed notation on a                   2. ID card issued by federal,                          issued by the Department of
   machine-readable immigrant                 state or local government                           State (Form FS-545)
   visa.                                      agencies or entities provided it                 3. Certification of Report of
4. Employment Authorization                   contains a photograph or                            Birth issued by the
   Document that contains a                   information such as name,                           Department of State (Form
   photograph (Form I-766)                    date of birth, sex, height, eye                     DS-1350)
5. In the case of a nonimmigrant              color and address.                               4. Original or certified copy of
   alien authorized to work from           3. School ID card with                                 a birth certificate issued by
   a specific employer incident               photograph.                                         a State, county, municipal
   to status, a foreign passport           4. Voter’s registration card.                          authority or outlying
   with Form I-94 or Form I-94A            5. U.S. Military card or draft                         possession of the United
   bearing the same name as the               record                                              States bearing an official
   passport and containing an              6. Military dependent’s ID card.                       seal.
   endorsement of the alien’s              7. U.S. Coast Guard Merchant                        5. Native American tribal
   nonimmigrant status, as long               Mariner card.                                       document.
   as the period of endorsement            8. Native American tribal                           6. U.S. citizen ID card (Form I-
   has non yet expired and the                document.                                           197)
   proposed employment is not              9. Driver’s license issued by a                     7. Identification Card for use
   yet expired and the proposed               Canadian government                                 of Resident Citizen in the
   employment is not in conflict              authority.                                          United States (Form I-179).
   with any restrictions or                                                                    8. Employment authorization
   limitations identified on the           For persons under age 18 who are                       document issued by the
   form                                    unable to present a document                           Department of Homeland
6. Passport from the Federated             listed above:                                          Security
   States of Micronesia (FSM) or
   the Republic of the Marshall            10. School record or report card.
   Island (RMI) with Form I-94             11. Clinic, doctor or hospital
   indicating nonimmigrant                     record
   admission under the Compact             12. Daycare or nursery school
   of Free Association Between                 record.
   the United States and the
   FSM or RMI




Page 6 of 6                                                                          Form: CBJ P001 rev: 09/06; 01/07; 05/08, 02/09, 04/09

								
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