3. ________________________________________________________ (______)_________________
Company Name Phone Number
_______________________________________ _______________ _______________________
Address City State Zip
____/____/_______ ____/____/______ _____________________________________________
Employed from Employed to Immediate Supervisor
__________________________ ___________________________________________
Job Title Reason for Leaving
List of Duties:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Are you an enrolled member of the Paskenta Band of Nomlaki Indians? Yes No
If you are claiming Native American Preference, please complete the following:
Are you an enrolled member of a Federally Recognized Tribe?
Yes No
Tribe: _____________________________________________________________________________________
How were you referred to the Paskenta Band of Nomlaki Indians Tribal Office?
Employee (First and Last Name):______________________
Job/Employment Fair: Internet/Social Media: Other: _______________
I understand the immigration Reform and Control Act of November 6, 1986 requires mw to prove the legality
of my residency or citizenship. I am also aware that the failure to provide such proof at the time of request may
legally force my termination. I understand that nothing contained in this employment application or in granting
of interview is intended to create a contract between myself and this company for either my employment or the
provision of any benefits. I further understand that if an employment relationship subsequently is established, I
will have the right to terminate my employment at anytime and the company will have a similar right. In addi-
tion I understand that no promise, representation or agreement contrary to the foregoing is binding on the com-
pany unless made in writing and signed by myself and an authorized representative of the company.
I certify that all answers in this application and additional information I may have submitted are true and com-
plete to the best of my knowledge. I understand that giving false information, misrepresenting facts, and mate-
rial omissions may be grounds for denial of employment or discharge if hired. I herby authorize investigation
of all statements provided during the application process and all references given to the Paskenta Band of
Nomlaki Indians, any and all pertinent information they may have, personal or otherwise, and release from all
liability or responsibility, Paskenta Band of Nomlaki Indians, any agent or either entity and all persons, compa-
nies or corporation providing information to Paskenta Band of Nomlaki Indians about me.
_____________________________________________________________
Print Name
_____________________________________________________________ _____/_____/_______
Applicant Signature Date
Referral Source
Authorization
_______
Initials
_______
Initials
Tribal Affiliation
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