Employment Application Form Completely fill out application and sign it. It is the applicant’s responsibility to ensure that the application is on file in Human Resources on the final filing date. Resumes are not acceptable in lieu of an application. Late applications will be rejected. Position Applying for: (required) Water Meter Reader (helper) Name (required) Street Address (required) City (required) ZIP Code (required) Phone Number (required) Email (required) Completion of the following four questions are required only if the position for which you are applying requires the possession of a valid California’s Driver’s License Drivers Licence Drivers Licence Class Drivers Licence State Drivers Licence Expiration Date Did you pass High School, pass the State High School Equivalency Exam, or do you possess a G.E.D. certificate? (required) Yes No Name of College or University Major Degree/Cerificate Unites Completed Are you now or have you ever been employed with the District? (required) No Yes Have you ever worked under or been known by another name? (required) Yes No Employee 1 Name Relationship to Employee 1 Employee 2 Name Relationship to Employee 2 Have you ever been discharged from employment or been forced to resign? (required)No Yes If Hired, can you provide proof of the legal right to work in the United States? (required)Yes Np Having read the job announcement which lists examples of job duties for the position, are you able to perform these duties with or without accomodation? (required)Yes No Have you ever worked under or been known by another name? (required)Yes No Bilingual Skill: What language(s) do you fluently speak, read and write other than English? (required) Do you qualify for credits based on U.S. Military Service? If Yes, submission of honroable wartime service, DD214 must be received with application (required)Yes No Please Read Carefully A resume is not acceptable in place of completing the following. Show your present or most recent job first. Show all employment during the past 10 years (or more, if qualifying Experience). Use a separate block for each Job Title (even those with same employer). Remember your acceptance depends on the completeness and accuracy of the information that is provided on this application. Important: To receive appropriate credit for work experience, date of employment must include month, day, and year. Special Licenses, Certificate, or Registration Requirements Fill in this section only if license(s) etc., are required for this job. Include title, date issued, date expires, serial number, and which state and/or agency issued it. Job Title (required) Describe your duties fully: (required) Reason for leaving (required) From Date (required) To Date (required) # of hours worked weekly (required) Organization Name and Address (required) May we Contact? (required)Yes No Job Title (required) Describe your duties fully: Reason for leaving From Date To Date # of hours worked weekly Organization Name and Address May we Contact? (required)Yes No Please identify and explain all periods of unemployment in excess of one month during the past 10 years: Reason for Leaving (required) From Date (required) To Date (required) Reason for Leaving (required) From Date (required) To Date (required) Reason for Leaving (required) From Date (required) To Date (required) The following information is requested to assist in implementing the District’s Affirmative Action and Equal Employment Opportunity policy and state and federal requirements. Submission of this information is strictly voluntary and will NOT be retained with your application but handled separately and confidentially for statistical purposes. How did you learn of this job opening?AVFCWD's Website Newspaper Publication Internet Water District's Office Other Accommodations NeededI can perform the essential functions of the position WITHOUT reasonable accommodations. I can perform the essential functions of the position WITH reasonable accommodations Disability: A person with a disability is an individual who:(1) has a physical or mental impairment or medical condition that limits one or more life activities, such as walking, speaking, breathing, performing manual tasks, seeing, hearing, learning, caring for oneself or working; (2) has a record or history of such impairment or medical condition; or (3) is regarded as having such an impairment or medical condition. I have a disabilityYes No Ethnic Affiliation (required)White – All persons having origins in any of the original peoples of Europe, the Middle East, or North Africa. Black or African American – All persons having origins in any of the black racial groups of Africa. Hispanic – All persons of Cuban, Mexican, Puerto Rican, Central or South American, or other Spanish culture, or origin, regardless of race. Not Hispanic or Latino Native Hawaiian or Other Pacific Islander – All Persons having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. Asian – All persons 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, or Vietnam. American Indian or Alaskan Native – All Persons having origins in any of the original peoples of North or South America (including Central America), and who maintains tribal affiliation or community attachment. I hereby certify that the above information is true and correct and is being submitted to Apple Valley Heights County Water District (AVHCWD) to substantiate my claim to monies paid to AVHCWD. I further certify that I have the authority and right to claim and receive payment of these monies and hereby release AVHCWD, its Board members, employees, representatives, attorneys and agents from all liability and further obligation with respect to this claim. Electronic Signature: (required) Electronic Signature: (required)By checking this box, I certify that I have completed this form and affirm that I am the above account holder and the information contained herein, including any and all additional documentation submitted via email, fax or mail, is complete and accurate. I further understand that all variances are subject to change, and I may be liable for back charges for providing false information. Signature of Applicant (Full Name) (required) There was a problem saving your submission. Please try again later. Please wait while your submission is being saved... Submitting...Submit Thank you, your submission has been received.
