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					                                    CITY OF ARTESIA
                                 18747 Clarkdale Avenue
                                    Artesia, CA 90701
                                       562/865-6262
                               Website: www.cityofartesia.us

                           APPLICATION FOR EMPLOYMENT

A separate application is required for each position. Use a typewriter or print. Applications
are kept on file for six (6) months. Answer all questions, incomplete or unsigned applications
will not be accepted. A resume does not substitute for a complete application! Use additional
sheets if necessary to include work experience, military or volunteer.
POSITION applying for ________________________________               Date: _______________
Name: ____________________________________________________________________
Street Address _________________________________________ Apt #_______________
City, State, Zip Code ________________________________________________________
Phone Number: Work/message: ________________________ Home: ________________
Driver’s License #_______________________ State ___ Check Type A___ B ___ C ___

Have you ever been employed or attended school while using a name other than the one
listed above? Yes ______ No______

If yes, please list the other name(s) and list the appropriate employer(s) or school(s) at which
you used a different name. ____________________________________________________


Have you ever been convicted of any crime which resulted in imprisonment, probation or the
payment of a fine or forfeiture of bail of $50 or more (a yes does not automatically disqualify
you)? Yes _____ No _____
If yes, please explain when, where and disposition of the case below: __________________
_________________________________________________________________________

Are you related to any current City of Artesia employee? No _____ Yes_____
Please list: ________________________________________________________________



Are you available to occasionally work overtime (before and after regular hours and/or
Saturdays or Sundays? Yes _____ No _____

Has your driver license ever been suspended or revoked (requiring for position which require
driving)? Yes _____ No _____
If yes, please explain: ________________________________________________________


Proof of eligibility to work in the United States is required.
Are you a U.S. Veteran? Yes _____ No ____
Have you ever been employed by the City of Artesia? ____
If yes, give dates: ___________________________________________________________

Who should the City notify in case of an emergency?
Name: ____________________________________ Phone Number: ________________
Address: _________________________________________________________________

Education/Training:
School/University                                                   Degree/Certification




EMPLOYMENT EXPERIENCE: Start with your most recent or current work experience, you
may exclude organizations which indicate race, national origin, religion, gender, disabilities,
or other protected classes. Please identify and explain any periods of unemployment on
a separate sheet of paper.
Employer: _________________________________ Phone Number: __________________
Address: ____________________________ City, State_____________________________
Your Job Title: ___________________________ Dates: From __________ To__________
Job Duties: ________________________________________________________________
_________________________________________________________________________
Name & Title of Supervisor: ___________________________________________________
Reason for Leaving: _________________________________________________________


Employer: _________________________________ Phone Number: __________________
Address: ____________________________ City, State_____________________________
Your Job Title: ___________________________ Dates: From __________ To__________
Job Duties: ________________________________________________________________
_________________________________________________________________________
Name & Title of Supervisor: ___________________________________________________
Reason for Leaving: _________________________________________________________
Employer: _________________________________ Phone Number: __________________
Address: ____________________________ City, State_____________________________
Your Job Title: ___________________________ Dates: From __________ To__________
Job Duties: ________________________________________________________________
_________________________________________________________________________
Name & Title of Supervisor: ___________________________________________________
Reason for Leaving: _________________________________________________________

Employer: _________________________________ Phone Number: __________________
Address: ____________________________ City, State_____________________________
Your Job Title: ___________________________ Dates: From __________ To__________
Job Duties: ________________________________________________________________
_________________________________________________________________________
Name & Title of Supervisor: ___________________________________________________
Reason for Leaving: _________________________________________________________
PROFESSIONAL REFERENCES: List three individuals, not related to you, who would have
knowledge about your qualifications for the position for which you are applying, such as
current or former co-workers, teachers, etc. Do not repeat names of supervisors listed under
Employment Experience.

 Name           City & State          Business             Home                 Years
                                      Phone #              Phone #             Acquainted




READ BEFORE SIGNING: The information contained on this application is correct to the
best of my knowledge. I understand that falsification, omission or miss-statement of material
fact can result in refusal to hire or, if hired, dismissal from employment. Employers listed in
this application are authorized to give any and all information, negative or positive,
concerning my previous employment. I understand that if hired I will be required to comply
with all rules and regulations. I understand the benefits and regulations and procedures may
be changed, modified, deleted or added to at any time at the City’s sole option and without
any prior notice. I understand and give my consent that as a condition of employment I may
be required to, both prior to and during employment, take and pass medical tests, including
drug and alcohol screens.

Signature _____________________________________               Date: ____________________

Print or type your name: ________________________________________
NOTE: Because of the high level of responsibility to the public, and in conjunction
with the City’s Drug-free Workplace Policy, the required post-offer, pre-employment
physical for full-time and regular part-time positions includes alcohol and drug testing
of body fluids.

This application is not an offer of employment nor is it an implied offer of employment. A
copy of your completed and signed application will be provided to you upon request.



                       OPTIONAL Affirmative Action Research Data

SEX:   ( ) MALE             ( )   FEMALE               BIRTHDATE: ______/______/______
                                                                       Month      day       year

MARITAL STATUS: _____________________________

POSITION APPLIYING FOR:                                Ethnic Group/Race: Please Mark One

______________________________________________         (   ) Caucasian/White    ( ) African American
                                                       (   ) American Indian    ( ) Asian
                                                       (   ) Pacific Islander   ( ) Other
PLEASE NOTE ANY PHYSICAL HANDICAP:                     (   ) Hispanic Surname
_______________________________________


                          HOW DID YOU HEAR OF THIS JOB OPENING?

_____ NEWSPAPER - Name of Newspaper ______________________________________________________
_____ PREVIOUSLY COMPLETED JOB INTEREST CARD
_____ ANOTHER CITY’S PERSONNEL DEPARTMENT
_____ SCHOOL PLACEMENT OFFICE – Name of School __________________________________________
_____ UNEMPLOYMENT OFFICE
_____ CITY OF ARTESIA WEBSITE
_____ OTHER CITY EMPLOYEE
_____ OTHER – Please Specify _______________________________________________________________

				
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