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First Name (required)

Last Name (required)

Present Address (required)

Years Lived Here (required)

Phone Number (required)

Alt. Phone Number

Why are you interested in this position? (required)

Please explain why you feel you are qualified to fulfill this position? (required)

Drivers License Number (required)

Drivers License Class and Expiration Date (required)

Professional or Occupational Licenses or Certificates: (list any other relevant licenses or certificates (include tupe, description, issuing agency, etc.).

If hired, can you furnish proof of age and verification of your legal right to work in the United States? (required)

Do you have adequate transportation to and from work? (required)

Are you capable of performing the essential job duties required for the position for which you are applying, with or without accommodation? (required)

Have you ever used another name or alias? (required)

If yes, please list.

Other qualifications: Summarize special job related skills and qualifications acquired through prior employment or other experiences.

High School Education (Include School Name):

Years Completed:

Diploma/ Degree:

Course of Study:

Specialized Training/ Skills and Experiences:

College Education (Include School Name):

Years Completed:

Diploma/ Degree:

Course of Study:

Specialized Training/ Skills an Experiences:

Trade Education (Include School Name):

Years Completed:

Diploma/ Degree:

Course of Study:

Specialized Training/ Skills an Experiences:

Present or Last Employer:

Supervisor:

Phone Number:

Address:

Employment From:

Employment To:

Job Title:

Job Duties Performed:

Exact Reason for Leaving:

Previous Employment:

Supervisor:

Phone Number:

Address:

Employment From:

Employment To:

Job Title:

Job Duties Performed:

Exact Reason for Leaving:

Previous Employment:

Supervisor:

Phone Number:

Address:

Employment From:

Employment To:

Job Title:

Job Duties Performed:

Exact Reason for Leaving:

Have you ever been terminated or asked to resign from any job? (required)

If yes, please give date(s) and provide details.

Please explain fully any gaps in your employment history.

May the District contact your current employer? (required)

If no, please explain why:

Please indicate any actual experience, special training and/or qualifications that you have which you feel are relevant to the position for which you are applying:

Please list any languages that you can read, write, or speak fluently:

Reference 1: Name (required)

Reference 1: Phone Number (required)

Reference 1: Relationship (required)

Reference 2: Name (required)

Reference 2: Phone Number (required)

Reference 2: Relationship (required)

Reference 3: Name (required)

Reference 3: Phone Number (required)

Reference 3: Relationship (required)

Resume (required)

I agree and understand that by signing the Electronic Signature Acknowledgment and Consent Form, that all electronic signatures are the legal equivalent of my manual/handwritten signature and I consent to be legally bound to this agreement.

APPLICANT'S STATEMENT & AGREEMENT In the event I am hired for employment with the Butte County Mosquito and Vector Control District (District), I will comply with all rules and regulations of this District. I understand that District policy requires me to submit to a test for the presence of drugs in my system and a physical, prior to employment and at any time during my employment, to the extent permitted by law. I also understand that any offer of employment may be contingent upon the passing of a physical examination. I consent to the disclosure of the results of any physical examination and related tests to the District. I also understand that I may be required to take other tests such as personality and honesty tests, prior to and during my employment. I understand that should I decline to sign this consent or take any of the above tests, my application for employment may be rejected or my employment may be terminated. I further understand that the District may contact my previous employers. I authorize those employers to disclose to the District all records and information pertinent to my employment with them. I authorize the persons named herein as personal references to provide the District with any pertinent information they may have regarding myself. I hereby state that all the information that I have provided on this application or any other documents completed in connection with my employment, and in any interview is true, accurate, and complete. I understand that if I am employed and any information provided to the District is found to be false or incomplete in any respect, I may be dismissed. I hereby state that I have read and understand the job description for the position that I am applying for and I understand that I must comply with all the requirements of the position, I can fulfill the physical requirements, with or without accommodation of the position, and I feel confident that I can meet the duties explained therein. If hired, I acknowledge that, as a public employee, the terms and conditions of my employment are fixed by statute and I acknowledge that I shall have no right to continued employment, except as provided by law. If any term or provision, or portion of this Agreement is declared void or unenforceable it shall be severed and the remainder of this Agreement shall be enforceable. If you have any questions regarding this statement, please ask a District representative before signing. I HEREBY ACKNOWLEDGE THAT I HAVE READ THE ABOVE STATEMENTS AND UNDERSTAND THEM. DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE "STATEMENT AND AGREEMENT."

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The District has a policy of requiring a physician’s physical fitness exam, together with urine drug testing of persons who have been offered employment. Individuals who are determined by the physician not to be physically fit for duty, or who test positive for controlled substances, will not be employed. If you have reason to believe that you will not pass a physician’s physical examination, or will test positive for the presence of controlled substances, or if you are unwilling to consent to such an examination or test if offered employment, it is recommended that you not submit an application.

All successful applicants are subject to a probationary period, in accordance with District Policy, Section 7005, Section 7005.6 and a pre-employment physicians urine and physical test in accordance with District Policy 7006.

The Butte County Mosquito and Vector Control District considers all applicants for all positions without regard to race, color, creed, gender, national origin, age, disability, genetic information, marital or veteran status, sexual orientation, or any other legally protected status.

"This institution is an equal opportunity provider and employer"

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