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Empapp Fillableform (Pinoleville Pomo Nation)

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Application for Employment
Pinoleville Pomo Nation
5
00 B Pinoleville Drive Ukiah, CA 95482
p. 707.463.1454
f. 707.463.6601
We consider applicants for positions without regard to race, color, religion, sex, national origin, age,
marital or veteran status, the presence of a non-job-related medical condition or handicap, or any
other legally protected status, with the exception that according to Title VII of the 1984 Civil Rights
Act, Section 701 (B) and 703 (I) preference in filing will be given to qualified American Indian
candidates.
(Please Print)
Position(s) Applied for
Date of Application
How did you learn about us?
Advertisement Friend Walk-In
Employment Agency Relative Other__________________________________
Personal Information
Last Name: First Name: Middle Name
Address Number Street City State Zip code
Telephone Number(s) Social Security Number
If you are under 18 years of age, can you provide required
proof of your eligibility to work?
Yes No
Have you ever filed an application with us before?
Yes No
If yes, give date___________
Are you currently employed?
Yes No
May we contact your present employer?
Yes No
Are you claiming Indian Preference?
Yes No
Documentation must be attached
Are you prevented from lawfully becoming employed in this
country because of VISA or Immigration Status?
Yes No
Proof of citizenship or immigration status will be required upon employment.
On what date would you be available for work? ____________
Are you available to work:
Full Time Part Time Shift Work Temporary
Are you currently on “Lay-Off” status and subject to recall?
Yes No
Can you travel if a job requires it?
Yes No
Have you ever had any job related military training?
Yes No
If yes, please describe____________________________________________________
Have you been convicted of a felony within the last 7 years?
Yes No
Conviction will not necessarily disqualify an applicant from employment
If Yes, explain __________________________________________________________
______________________________________________________________________
Are you physically or otherwise unable to perform the duties of the job
for which you are applying? Yes No
Employment Experience
Start with your present or last job. Include any job-related military service assignments and
volunteer activities.
Employer
Dates Employed
From To
Work Performed
Address
Telephone Number(s)
Hourly Rate/Salary
Starting Final
Job Title
Reason for Leaving
Employer
Dates Employed
From To
Work Performed
Address
Telephone Number(s)
Hourly Rate/Salary
Starting Final
Job Title
Reason for Leaving
Employer
Dates Employed
From To
Work Performed
Address
Telephone Number(s)
Hourly Rate/Salary
Starting Final
Job Title
Reason for Leaving
Employer
Dates Employed
From To
Work Performed
Address
Telephone Number(s)
Hourly Rate/Salary
Starting Final
Job Title
Reason for Leaving
If you need additional space, please continue on the back of this form.
Special Skills and Qualifications
Please let us know of any Special Skills and Qualifications in this box.
Education
List professional, trade, business or civic activities and offices held:
You may exclude memberships that would reveal sex, race, religion, national origin, age, ancestry, handicap or other protected status
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
References
High School
Undergraduate
College/University
Graduate/Professional
School Name
and Location
Years Completed
9 10 11 12
1 2 3 4
1 2 3 4
Diploma/Degree
Describe Course of
Study
Describe any
specialized training,
apprenticeship, skills,
and extracurricular
activities
Describe any honors
you have received
State any additional
information you feel
may be helpful to us in
considering your
application
Give name, address and telephone number of three references that are not related to you and are not
previous employers.
1. ________________________________________________________________________
2. ________________________________________________________________________
3. ________________________________________________________________________
Statement
The information I am presenting in this application is true and correct to the best of my
knowledge, and I understand that any false statement, misrepresentation, or omission, shall be
sufficient cause for rejection or dismissal in the event I am employed by the Tribe. I understand
and agree that, if hired, I will conform to the rules and regulations of the Tribe, and further agree
that my employment is for no definite period and I have the right to terminate my employment at
any time, for any reason, or no reason, and the Tribe retains a simple right regarding the
discontinuation of my employment. The Tribe, in considering my application for employment, may
verify the information set forth on this application and obtain additional information relating to my
background. I authorize all persons, schools, companies, corporations, credit bureaus, law
enforcement agencies, and previous employers to release any information concerning my
background. I understand any offer of employment is contingent on my successful completion of
a drug screening test.
Date Agreed____________________________ Signature ________________________
Emergency Contact
Name __________________________________ Relationship ______________________
Address_________________________________ Phone #_________________________
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Completed 27 July 2020

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