Fillable Experience Incomplete Other 1. FOR WHAT POSITION ARE (Bay Area Air Quality Management District)

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Experience Incomplete Other 1. FOR WHAT POSITION ARE (Bay Area Air Quality Management District)

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EMPLOYMENT APPLICATION
For Human Resources Use Only
Submit to: 375 BEALE STREET, SUITE 600
SAN FRANCISCO, CA 94105
(415) 749 - 4980
Application Accepted
Application Rejected
Education
Experience
License
Incomplete
Late
Other
Comments:______________________________
1. FOR WHAT POSITION ARE YOU APPLYING? (To be considered, you must be specific)
2. NAME
First
Middle
3. ADDRESS (If address is temporary, please indicate)
Street
City
State
Zip
4. PHONE
Home
(OK to call you at work?)
Office
(OK to leave message?)
EMAIL (optional)
5. IMMIGRATION REFORM & CONTROL ACT
If hired, can you provide proof of your legal right to
work permanently in the United States?
6. If you are under the age of 18, can you submit a work
permit after an offer of employment has been made?
Yes No Yes No
7. Have you ever been a member of the California Public
Employees Retirement System?
8. Are you related to any District employee or Board
member? (If yes, give name and relationship)
Yes
No Yes
No
9. When are you available for work?
NOTE: Some or all positions may require possession of a valid California driver’s
license. Employees who drive on District business to carry out job-related duties
must possess a valid California driver’s license for the class of vehicle driven and
meet automobile insurability requirements of the District including review of a
recent DMV history.
10. EDUCATION
CIRCLE HIGHEST GRADE COMPLETED
NAME OF SCHOOL
LOCATION
GED
1 2 3 4 5 6 7 8 9 10 11 12
Yes
No
COLLEGE, BUSINESS OR TRADE
SCHOOLS ATTENDED
From
Mo/Yr
To
Mo/Yr
Major
Total Units Earned
Degree
Received
Sem
Qtr
POSTGRADUATE STUDY
11. PROFESSIONAL REFERENCES (Give contact information for persons who are familiar with your qualifications)
NAME ADDRESS PHONE
1.
2.
3.
12. EXPERIENCE
List present or most recent position first, and go back at least ten years. Include all relevant experience. You may attach
additional sheets, if necessary.
Name and Address of Employer
From
Mo/Yr
To
Mo/Yr
# of Hrs. Worked Per Week
Position Title
Full-time Part-time
Earnings
$ per
Supervisor’s Name/Title
May we contact him/her?
Now Later
Supervisor’s Phone
Description of Your Duties
Reason for Leaving:
Name and Address of Employer
From
Mo/Yr
To
Mo/Yr
# of Hrs. Worked Per Week
Position Title
Full-time Part-time
Earnings
$ per
Supervisor’s Name/Title
May we contact him/her?
Now Later
Supervisor’s Phone
Description of Your Duties
Reason for Leaving:
Name and Address of Employer
From
Mo/Yr
To
Mo/Yr
# of Hrs. Worked Per Week
Position Title
Full-time Part-time
Earnings
$ per
Supervisor’s Name/Title
May we contact him/her?
Now Later
Supervisor’s Phone
Description of Your Duties
Reason for Leaving:
13. I hereby certify that all statements made in this application are true and complete, and I understand that any misstatements
or omissions of material facts may subject me to disqualification or dismissal. Further, by signing below, I hereby authorize the
Bay Area Air Quality Management District to contact the professional references listed on this application.
DATE SIGNATURE (In Full)
BAAQMD EMPLOYMENT QUESTIONNAIRE
THE FOLLOWING INFORMATION WILL BE REMOVED FROM THIS APPLICATION PRIOR TO ITS REVIEW
The information on this form is voluntary and confidential. This information will be separated from your application and will not
be used to evaluate an applicant’s suitability for a position.
NAME
First
Middle Last
SEX Female Male
ETHNIC SELF-IDENTIFICATION
Hispanic or Latino —
A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture
or origin regardless of race.
White (Non Hispanic or Latino) — All persons having origins in any of the original peoples of Europe, North Africa
or the Middle East.
Black or African American (Non Hispanic or Latino) —
A person having origins in any of the black racial groups
of Africa.
Asian (Non 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.
Native Hawaiian or Other Pacific Islander (Non Hispanic or Latino) — A person having origins in any of the
peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
American Indian or Alaska Native (Non Hispanic or Latino) — A person having origins in any of the original
peoples of North
and South America (including Central America), and who maintain tribal affiliation or community attachment.
Two or More Races (Non Hispanic or Latino) — Persons who identify with two or more racial categories named
above.
Are you a Veteran? Yes No
HOW DID YOU FIND OUT ABOUT THIS POSITION?
BAAQMD Bulletin Board
BAAQMD Employee
Mailed Notice
Website (Please be specific)
Newspaper (Please be specific)
Professional Publication (Please be specific)
Other (Please be specific)
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Save PDF to desktop
Email
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Experience Incomplete Other 1. FOR WHAT POSITION ARE (Bay Area Air Quality Management District)

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Completed 27 January 2021

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