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NEVADA IRRIGATION DISTRICT

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NEVADA IRRIGATION DISTRICT
Application for Temporary/Seasonal Assignment
Equal Opportunity Employer ~ Drug Free Workplace
M/F/D/V
RETURN TO: NEVADA IRRIGATION DISTRICT – HUMAN RESOURCES DEPARTMENT
1036 W. Main Street, Grass Valley, CA 95945
Phone: 530-273-6185 Fax: 530-271-6874
Email: hr@nidwater.com
Conditions of temporary/seasonal assignment are stated at the end of this form. Please read carefully before
you sign this application. (Application must be completed in full even if attaching a resume.)
It is our policy to provide equal employment opportunity to all qualified persons without regard toward race, age, color, sex,
gender, religion, veteran status, national origin, physical or mental disability, sexual orientation, marital status, or any other
consideration made unlawful by federal, state or local laws.
ASSIGNMENT APPLYING FOR _____________________________________
DATE _____________
PERSONAL INFORMATION:
________________________________________________________________________________________________________
Last Name Middle First Name
______________________________________________________________________________________________
Address City State Zip Code
_______________________________ ______________________________ _____________________________
Home Phone Cell Phone Email Address
GENERAL INFORMATION:
Have you ever worked for NID?
☐ Yes ☐ No
Are you under 18?
☐ Yes ☐ No
Do you have any relatives presently employed with NID?
☐ Yes ☐ No
Name(s) ________
_______________________________
Can you provide valid documentation establishing
your identity and eligibility to be legally employed in
the United States? ☐ Yes ☐ No
Have you ever been discharged from any employment or asked to resign? ☐ Yes ☐ No
If Yes, please explain:
Have you ever served in the U.S. Military?
☐
Yes
☐
No
From: _____________ To: ______________ Branch: ______________________
EDUCATION:
Name and Location
Years
Completed
Major/Type of
Diploma or Degree
Did you
Graduate?
High School
Business/Trade School
College
Graduate/Professional
Are you a current or former member of CalPERS?
Yes No
☐ Yes ☐ No
Do you have a valid driver's license?
EMP
LOYMENT HISTORY: Begin with your most recent Employment including any gaps of employment.
Do not write “Refer to Resume” (Attach additional sheets if necessary)
Dates of Employment
From (Mo/Yr) _____________ To (Mo/Yr) ______________
Position/Job Title:
Name of Employer:
Address:
Phone Number:
Supervisor Name/Title:
Job Responsibilities:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Reason for Leaving:
May We Contact? ☐ Yes ☐ No
Position/Job Title:
Address:
Supervisor Name/Title:
Job Responsibilities:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Reason for Leaving:
May We Contact? ☐ Yes ☐ No
Dates of Employment
From (Mo/Yr) _____________ To (Mo/Yr) ______________
Position/Job Title:
Name of Employer:
Address:
Phone Number:
Supervisor Name/Title:
Job Responsibilities:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Reason for Leaving:
May We Contact? ☐ Yes ☐ No
Dates of Employment
From (Mo/Yr) _____________ To (Mo/Yr) ______________
Position/Job Title:
Name of Employer:
Address:
Phone Number:
Supervisor Name/Title:
Job Responsibilities:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Reason for Leaving:
May We Contact? ☐ Yes ☐ No
LICE
NSES OR CERTIFICATES OBTAINED:
ADDITIONAL EXPERIENCE OR QUALIFICATIONS:
List any other experience, skills or other qualifications, which you believe should be considered in evaluating your
qualifications for employment.
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
ACKNOWLEDGEMENT
PLEASE READ BEFORE SIGNING
I CERTIFY THAT ALL ANSWERS GIVEN BY ME ARE TRUE, ACCURATE AND COMPLETE; I UNDERSTAND THAT THE
FALSIFICATION, MISREPRESENTATION OR OMISSION OF FACT ON THIS APPLICATION (OR ANY OTHER
ACCOMPANYING OR REQUIRED DOCUMENTS) WILL BE CAUSE FOR DENIAL OF ASSIGNMENT OR IMMEDIATE
TERMINATION OF ASSIGNMENT, REGARDLESS OF WHEN OR HOW DISCOVERED.
Questions regarding this statement should be directed to the Human Resources department before signing. The
application will be given every consideration, but its receipt does not imply that I will be employed.
It is the policy of Nevada Irrigation District to afford equal opportunity to all applicants without regard to age, race,
religion, color, sex, national origin, marital status, veteran status, expunged juvenile records, or pregnancy, and to
afford equal opportunities to individuals with a disability, and other characteristic protected by Federal, State or
Local law.
I acknowledge that I have read and understand the above statements and hereby grant permission to confirm the
information supplied on this application by me.
APPLICANT SIGNATURE____________________________________________ DATE __________________________
FOR HUMAN RESOURCES ONLY
DATE RECEIVED NOTIFICATION RESULT
Revised September 2018
Type: Number: Expiration Date:
Type: Number: Expiration Date:
Type: Number: Expiration Date:
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NEVADA IRRIGATION DISTRICT

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Completed 4 November 2021

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