Fillable APPLICATION FOR EMPLOYMENT (Susanville Indian Rancheria)

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APPLICATION FOR EMPLOYMENT (Susanville Indian Rancheria)

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The APPLICATION FOR EMPLOYMENT (Susanville Indian Rancheria) form is 4 pages long and contains:

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  • 45 check-boxes
  • 101 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Susanville Indian Rancheria

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SUSANVILLE INDIAN RANCHERIA LASSEN INDIAN HEALTH CENTER
SIR GAMING COMMISSION
HUMAN RESOURCE DEPARTMENT FOR OFFICE USE
745 Joaquin Street Date received:______________
Susanville, CA 96130
APPLICATION FOR EMPLOYMENT
This application is considered for one hundred eighty (180) days. If you wish to be considered for later employment, you must renew your application in
person at the Human Resource Department.
P
ERSONAL
1. Last Name First Middle
2. Social Security Number
3. Street Address
4. Date of Birth (Required for background
checks)
5. City, State, Zip
6. Home Telephone
7. Position Desired
8. Business Telephone
9. Do you have the ability to perform job-related functions? Yes No
If not, what are your limitations?
10. Pay Expected
11. Have you ever applied for work with the Susanville Indian Rancheria before?
Yes No If so, when_________________________________________
12. When will you be available to begin
work?___________________________
13. Are you related to a Tribal Business Council member or employee of the Susanville Indian Rancheria?
Yes No If yes, please give name(s)_____________________________________________________________________
14. Are you applying under Indian Preference (42 CFR 36.221)? Yes No Tribe:__________________________________________
YOU MUST ATTACH A COPY OF YOUR ENROLLMENT CARD FOR INDIAN PREFERENCE. Have you attached a copy? Yes No
15. Fluent in languages other than English: _______________ Read Y N Write Y N
16. List skills that qualify you for this position:____________________________________________________________________________________
________________________________________________________________________________________________________________________
17. Special training or skills (languages, machine operation, etc.)
MS Excel MS Outlook Computer MS Word _____wpm 10 Key Dictaphone
Other Skills ______________________________________________________________________________________________
EDUCATION
School
Name and Location of School
Course of Study
No. of Years
Completed
Did you
Graduate?
18. Graduate
19.
20.
21.
22.
Yes
No
23. College
24.
25.
26.
27.
Yes
No
28. Business/
Trade/Technical
29.
30.
31.
32. Yes
No
33. High School
34.
35.
36.
37. Yes
No
38. Have you ever been convicted of anything other than a minor traffic violation? Y N
If yes, please explain on a separate page. If you are hired, this separate page will not appear in your personnel file.
39. The Crime Control Act, P.L. 101-647, and Indian Child Protection & Family Violence Prevention Act, P.L. 101-630 of 1990 requires the
following questions of persons applying for positions that involve regular contact with or control over Indian children:
1. Have you ever been arrested for or charged with a crime involving a child? Y N
2. Have you ever been found guilty of, or entered in a plea of nolo contendere (no contest), or guilty to, any felonious or misdemeanor offense
under Federal, State, or Tribal law involving crimes of violence, sexual assault, sexual molestation, sexual exploitation, sexual contact or
prostitution, or crimes against persons? Y N
If yes, please explain on a separate page. If you are hired, this separate page will not appear in your personnel file.
40. If an offer of employment is made, prior to your commencement of employment duties, you may be required to undergo a medical examination
Application for Employment Page 2
LIST OF WORK RELATED REFERENCES
List three business/work references that are not related to you and are not previous supervisors. If not applicable, list three school or personal
references that are not related to you.
Name
Telephone
Years Known
Relationship to Applicant
Type of Reference
41.
42.
43.
44.
45. Personal
Professional
46.
47.
48.
49.
50. Personal
Professional
51.
52.
53.
54.
55.
Personal
Professional
E
MPLOYMENT
MUST BE DETAILED AND ACCURATE TO AVOID DISQUALIFICATION. Please give accurate, complete full-time and part-time employment record.
Start with you present or most recent employer. Referral to resumes or other submitted documentation under employment history is not acceptable.
Resume may be submitted as additional information only.
56. Company Name
57. Telephone
58. Address (include Street, City, State and Zip)
59. Employed – (State month and year)
From To
60. Name of Supervisor
61. Weekly pay
Start Last
62. State Job Title and Describe Your Work
63. Reason for Leaving
64. May we contact now? Yes No If no, please explain:
65. Company Name
66. Telephone
67. Address (include Street, City, State and Zip)
68. Employed – (State month and year)
From To
69. Name of Supervisor
70. Weekly pay
Start Last
71. State Job Title and Describe Your Work
72. Reason for Leaving
73. Company Name
74. Telephone
75. Address (include Street, City, State and Zip)
76. Employed – (State month and year)
From To
77. Name of Supervisor
78. Weekly pay
Start Last
78. State Job Title and Describe Your Work
80. Reason for Leaving
81. Explain any gaps in employment:
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
I authorize investigation of all statements on this application. It is further understood that misrepresentation or omission of facts called for herein will result
in cancellation of this application or dismissal from Susanville Indian Rancheria if employed. Upon employment, I will submit genuine documentation that
establishes employment eligibility and authorization to be legally employed within the United States.
The first year of regular employment is considered to be the employee’s Probationary Period. A probationary employee may resign or be discharged for
any reason during the Probationary Period without the employee or Susanville Indian Rancheria/Lassen Indian Health Center being required to give the
other party prior notification. No representative other than the Tribal Chair for the Susanville Indian Rancheria, with the authority of the Tribal Business
Council or Health Board, has the authority to enter into any employment agreement.
82. 83.
Signature Date
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signature
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Application for Employment Page 3
APPLICANT STATEMENT OF UNDERSTANDING AND RELEASE OF LIABILITY
AS WELL AS REQUIREMENTS FOR A CRIMINAL BACKGROUND CHECK
AUTHORIZATION TO RELEASE INFORMATION
I, 84._______________________, am applying for a position with the Susanville Indian Rancheria. I hereby
signify my willingness to appear for interviews in regards to my application and authorize Susanville Indian
Rancheria's representatives to consult with other institutions with which I have been associated and personal
references who may have information bearing on my professional competence, character, ethical qualifications,
assaultive behaviors and criminal convictions. I further consent to the release/disclosure to the Susanville
Indian Rancheria all educational, professional and criminal records that may be material to an evaluation of my
qualifications and competence, as well as my ethical behavior for staff membership.
The Susanville Indian Rancheria will not hire or employ persons, nor allow persons to volunteer, for positions
that are subject to the Rancheria’s criminal background investigation policy (subsection 5 of Section 3 of the
SIR Personnel Policies & Procedures), who do not meet the minimum standards of character described in that
policy. The required background investigations are intended to determine suitability for employment.
Each individual age 18 or over who volunteers to assist or is employed in an area identified by the Susanville
Indian Rancheria as having regular contact with or control over children, will be subject to a criminal background
investigation, including fingerprinting. All persons subject to this requirement shall have their fingerprints
obtained by the Susanville Indian Rancheria Gaming Commission for processing through the FBI and State
Criminal history repositories for all States that are listed as current and former residences on the employment
application or volunteer form.
You have the right to obtain a summary of the criminal history report made available to the Susanville Indian
Rancheria Human Resources Department and to challenge the accuracy and completeness of any information
contained in the report.
Your signature below constitutes consent to the conduct of a criminal background investigation. Refusal will
prohibit your employment or ability to volunteer in any of the areas identified by the Susanville Indian Rancheria
as requiring a criminal background investigation.
I hereby release from liability all representatives, facilities, educational institutions and training programs that I
have attended and/or worked for, from their acts performed in good faith and without malice in connection with
evaluating my credentials and qualifications. I also hereby release from any liability any and all individuals and
organizations that provide information to the Susanville Indian Rancheria's staff in good faith and without malice
concerning my, education, professional competence, ethics, character and other qualifications.
I certify that the statements/documents that I have made/provided in this application are true, complete, and
correct to the best of my knowledge and belief, and are made in good faith.
I fully understand that a false statement to any question in this application or the misrepresentation of
information otherwise provided may cause my application to be disqualified or constitute immediate termination
if employed.
I have read and understand above statement.
85. 86.
Signature Date
87. 88.
Social Security Number Driver’s License Number
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signature
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Application for Employment Page 4
FOR EMPLOYER’S USE ONLY
Testing Results
Tests Administered
Raw Score
Rating
Analysis and Comments
Math
Grammar
Spelling
Vocabulary
Computer
Knowledge
Office Skills
Other
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APPLICATION FOR EMPLOYMENT (Susanville Indian Rancheria)

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Completed 20 July 2020

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