______________________________________________________________________________________________
Name (First, Middle Initial, Last )
______________________________________________________________________________________________
Mailing Address
____________________________________________________________ _________ _______________
City State Zip
(____)__________________ ____________________________________________________________________
Home/Cell Phone Address Email
____________________________________________________________________ (____)_________________
Emergency Contact Phone Number
Position Applying For: ___________________________________ Requested Pay range: $_______________
Type of work applying for: Full Time Part Time Temporary
Have you applied here before? Yes No
Do you have a legal right to be employed in the United States? Yes No
(If yes you will be required to provide proof upon hire)
Are you at least 18 years old? Yes No
Do you have a valid Drivers License? Yes No DL#______________ State: __________
Have you ever been convicted of a Felony? Yes No (If yes you will be required to provide date and reason )
Do you have a high school diploma? Yes No
Candidate Information
Paskenta Band of Nomlaki Indians
Employment Application
Employment preferences are provided to qualified Paskenta Band of Nomlaki Tribal Members. The Paskenta
Tribal Office strives to be an equal opportunity employer dedicated to the policy of nondiscrimination based
on race, sex, marital status, sexual orientation, religion, national origin, age mental or physical disability,
veteran status or any other non job-related factor. Any person requiring reasonable accommodation in the
application process should contact the Human resources.
Employment applications are required for all positions. Applications will only be accepted for open positions
and will remain “active” for 60 days. Please complete all information.
Please print legibly. A resume will not substitute for an application.
Application
Institution City/State
Diploma/Degree ob-
tained (Yes/No) Field of Study Year Graduated
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Education
List any special skills (computer, technical, mechanical, etc.). List professional certifications and/or license you currently
hold (CPR, EMT etc.):
_________________________________________________________________________________________________
_________________________________________________________________________________________________
1. ________________________________________________________ (______)_________________
Company Name Phone Number
_______________________________________ _______________ ____________ ___________
Address City State Zip
____/____/_______ ____/____/______ ____________________________________
Employed from Employed to Immediate Supervisor
__________________________ ____________________________________________
Job Title Reason for Leaving
List of Duties:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
2. ________________________________________________________________ (______)_________________
Company Name Phone Number
_________________________________ ________________ ____________ ________________
Address City State Zip
____/____/_______ ____/____/______ _______________________________________________
Employed from Employed to Immediate Supervisor
__________________________
_______________________________________________________
Job Title Reason for Leaving
List of Duties:
_________________________________________________________________________________________________
_______________________________________________________________________________________
___________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Skills
Previous Employment
Languages Read Write Speak
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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
click to sign
signature
click to edit