Date and Time Stamp

(Human Resources Use Only)

/ APPLICATION FOR EMPLOYMENT
Personnel Department
7100 S. Garfield Boulevard
Bell Gardens, CA 90201
(562) 806-7700 Main line
An Equal Opportunity/Affirmative Action Employer
POSITION APPLIED FOR: / Job ID#
PERSONAL INFORMATION
LAST NAME / FIRST NAME / MIDDLE INITIAL / PRIMARYTELEPHONE NUMBER
ADDRESS: (NUMBER STREETAPT #) / ALTERNATETELEPHONE NUMBER
CITY / STATE / ZIP CODE / E-MAIL ADDRESS
Are you related (by blood or marriage) to any Bell Gardens City employee? No Yes(if yes, complete information below)
EMPLOYEE NAME / RELATIONSHIP / DEPARTMENT / THEIR JOB TITLE
Have you ever been terminated or resigned in lieu of termination? No Yes(if yes, complete information below)
DATE / POSITION / JOB TITLE / EXPLANATION / REMARKS
Are you willing to work: / ** For Positions that Require Driving **
Full Time?
Part Time?
Temporary?
Seasonal?
On-call? / No Yes
No Yes
No Yes
No Yes
No Yes / Days?
Nights?
Weekends?
Holidays?
Shift Work? / No Yes
No Yes
No Yes
No Yes
No Yes / Do you have a valid California driver’s license? no yes
Driver License Information
State / Number
Class / Endorsement / Expiration Date (xx/xx/xxxx)
/
Public Employees Retirement System (PERS) Status / ** Police Officer / Recruit Applicants only **
Are you currently a member of PERS?No Yes
Have you ever been a member of PERS?No Yes / Are you a U.S. Citizen or a permanent resident alien who is eligible for and has applied for citizenship?No Yes
EDUCATION AND TRAINING
Did you graduate from high school?
Did you earn a GED? / No Yes
No Yes / Name of High School (or Institution that provided GED)
HIGEST GRADE COMPLETED
1 2 3 4 5 6 7 8 9 10 11 12 / City and State
*** Must attach copies of all degrees and certificates received at time of application ***
Names of Colleges, Universities and/or Military Academies attended / Location
(City, State) / Number of Units
Semester Quarter / Major / Emphasis / Graduated? / Degree / Certificate Received
1) / No Yes
2) / No Yes
3) / No Yes
Trade or Vocational
Schools attended / Location / Credit Type (#)
Units Hours / Area of Study/Trade / Degree / Certificate
1) / No Yes
2) / No Yes
FOR OFFICE USE ONLY
HR Review / Dept Review / Has all required License(s)
No Yes / Screening Disposition
NQ DEF MSR MMR AMQ / Remarks
- READ CAREFULLY BEFORE BEGINNING THIS SECTION -
  1. Read the experience requirements in the job bulletin before completing this section.
  2. Begin with your most recent job. List different positions with the same employer separately.
  3. Account for all time within the last 10 years, including military, self-employment, volunteer and any time you were not employed for any reason. Employment and personal references may be verified.
  4. List all periods of employment with the City of Bell Gardens, regardless of when they occurred.
  5. Fill out completely. Do not leave any blanks. Attach an additional sheet if you need more space.
  6. Incomplete applications may not receive full consideration.
  7. Resumes are NOT accepted in place of any part of this application. However, you may include a résumé in addition to this application for consideration.
  8. May we contact your present employer? Yes No

EXPERIENCE
FROM / TO / Title of Your Position: / Number of hours workedper week: / Number of Employees you supervised:
(Month / Year) / (Month / Year)
Salary
$ / Hourly
Monthly / Weekly
Annually / Duties of Your Position:
Company or
Employer:
Street
Address:
City, State
and Zip:
Phone
Number:
Supervisor’s
Name:
Supervisor’s
Title: / Reason for leaving or wanting
to leave if presently employed:
FROM / TO / Title of Your Position: / Number of hours worked per week: / Number of Employees you supervised:
(Month / Year) / (Month / Year)
Salary
$ / Hourly
Monthly / Weekly
Annually / Duties of Your Position:
Company or
Employer:
Street
Address:
City, State
and Zip:
Phone
Number:
Supervisor’s
Name:
Supervisor’s
Title: / Reason for leaving:
FROM / TO / Title of Your Position: / Number of hours worked per week: / Number of Employees you supervised:
(Month / Year) / (Month / Year)
Salary
$ / Hourly
Monthly / Weekly
Annually / Duties of Your Position:
Company or
Employer:
Street
Address:
City, State
and Zip:
Phone
Number:
Supervisor’s
Name:
Supervisor’s
Title: / Reason for leaving:
JOB ID# / POSITION APPLIED FOR: / APPLICANT NAME (print):
EXPERIENCE (Cont’d): You may attach a copy of this page to reflect additional information.
FROM / TO / Title of Your Position: / Number of hours workedper week: / Number of Employees you supervised:
(Month / Year) / (Month / Year)
Salary
$ / Hourly
Monthly / Weekly
Annually / Duties of Your Position:
Company or
Employer:
Street
Address:
City, State
and Zip:
Phone
Number:
Supervisor’s
Name:
Supervisor’s
Title: / Reason for leaving or wanting
to leave if presently employed:
FROM / TO / Title of Your Position: / Number of hours worked per week: / Number of Employees you supervised:
(Month / Year) / (Month / Year)
Salary
$ / Hourly
Monthly / Weekly
Annually / Duties of Your Position:
Company or
Employer:
Street
Address:
City, State
and Zip:
Phone
Number:
Supervisor’s
Name:
Supervisor’s
Title: / Reason for leaving:
FROM / TO / Title of Your Position: / Number of hours worked per week: / Number of Employees you supervised:
(Month / Year) / (Month / Year)
Salary
$ / Hourly
Monthly / Weekly
Annually / Duties of Your Position:
Company or
Employer:
Street
Address:
City, State
and Zip:
Phone
Number:
Supervisor’s
Name:
Supervisor’s
Title: / Reason for leaving:
Periods Of Unemployment
From: / To: / Reason:
From: / To: / Reason:
From: / To: / Reason:
From: / To: / Reason:
JOB ID# / POSITION APPLIED FOR: / APPLICANT NAME (print):
CONVICTION RECORD (required from all applicants)
HAVE YOU EVER BEEN CONVICTED OF A CRIME (INCLUDING A PLEA OF GUILTY OR NO CONTEST) WHICH RESULTED IN A CRIMINAL CONVICTION (THAT HAS NOT BEEN JUDICIALLY ORDERED SEALED OR EXPUNGED)? (EXCLUDE MISDEMEANOR CONVICTIONS FOR MARIJUANA-RELATED OFFENSES MORE THAN TWO YEARS OLD; NOTWITHSTANDING ANY OF THE PRECEDING, YOU SHOULD NOT DISCLOSE CONVICTIONS THAT ARE OVER TWO YEARS OLD AS OF THE DATE THAT YOU COMPLETE THIS APPLICATION FOR VIOLATION OF HEALTH AND SAFETY CODE SECTIONS 11357, 11360, 11364, 11365 OR 11550, AS THOSE STATUTES RELATED TO MARIJUANA PRIOR TO JANUARY 1, 1976 OR A STATUTORY PREDECESSOR TO THOSE STATUTES.) No Yes
IF YES, BRIEFLY DESCRIBE THE NATURE OF THE CRIME(S), THE DATE AND THE PLACE OF CONVICTION(S). THE CASE NUMBER, AND THE LEGAL DISPOSITION OF THE CASE(S):
THE CITY WILL NOT DENY EMPLOYMENT TO ANY APPLICANT SOLELY BECAUSE THE PERSON HAS BEEN CONVICTED OF A CRIME. THE CITY, HOWEVER, MAY CONSIDER THE NATURE, DATE AND CIRCUMSTANCES OF THE OFFENSE AS WELL AS WHETHER THE OFFENSE IS RELEVANT TO THE DUTIES OF THE POSITION.
Have you ever been convicted of a breach or violation of any ordinance or law, other than a minor traffic violation?
No Yes / If yes, provide the information requested below for each conviction (continuing on back of page if necessary). Be specific, give name and code number of offense, not simply misdemeanor or felony.
OFFENSE # / NAME / OFFENSE # / NAME / OFFENSE # / NAME
DATE / DATE / DATE
LOCATION / LOCATION / LOCATION
SENTENCE/FINE / SENTENCE/FINE / SENTENCE/FINE
CERTIFICATION AND WAIVER
CERTIFICATION: PLEASE READ BEFORE SIGNING. IF NOT SIGNED, APPLICATION MAY BE REJECTED.
I certify under penalty of perjury that the information I entered on this application is true and complete to the best of my knowledge.
I understand that the City may reject my application if it discovers any issue(s)/incident(s) which occurred during my current or former employment, and I did not disclose such on this job application. I also understand that any false, incomplete, or incorrect statements may result in my disqualification from the application process, removal from an eligible list or dismissal from employment with the City.
SIGNATURE: / DATE:
City of Bell Gardens
An Equal Opportunity/Affirmative Action Employer
JOB ID# / POSITION APPLIED FOR: / APPLICANT NAME (print):
VOLUNTARY STATISTICAL INFORMATION
This information is requested to assist the City in complying with Federal and State reporting requirements. The data you provide will be detached from your application and used only for research and statistical purposes. All information in this section is confidential; no one connected with the hiring process will have access to this information.
DEMOGRAPHICS / RACE / ETHNICITY
GENDER: Male
Female
AGE GROUP: Under 21
21 - 39
40 and over / Check only one (primary) race / ethnicity
Native American / Alaskan Native
Asian Or Pacific Islander
Black, African American
Hispanic
White, Caucasian / If multi-racial, please check all that apply
Native American / Alaskan Native
Asian Or Pacific Islander
Black, African American
Hispanic
White, Caucasian
RACE / ETHINICITY DEFINITIONS
Definitions for Race/Ethnicity as defined by the United States Equal Employment Opportunity Commission (EEOC). This information is used for reporting purposes only, as required by the EEOC.
AMERICAN NATIVE/ ALASKAN NATIVE / All persons having origins in any of the original peoples of North America, and who maintain cultural identification through tribal affiliation or community recognition.
ASIAN OR PACIFIC ISLANDER / All persons having origins in any of the original peoples of the Far East, Southeast Asia, the Indian subcontinent, or the Pacific Islands. (e.g., China, Japan, Korea, Samoa and the Philippine Islands)
BLACK, AFRICAN AMERICAN / (Not of Hispanic origin) All persons having origins in any of the racial groups of Africa.
HISPANIC / All persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of race.
WHITE, CAUCASIAN / (Not of Hispanic origin) All persons having origins in the original peoples of Europe, North Africa or the Middle East.
I FIRST LEARNED ABOUT THIS JOB OPENING THROUGH……(check all that apply)
Bell Gardens website
Job posting at Bell Gardens City Hall
Received Bell Gardens interest card in mail
Job Posting at other government agency
Friend or relative
City employee:
Other: / Job Fair (specify location/event name):
College/university job posting (school):
Career Center (organization or school):
Internet job posting (specify site):
Newspaper / Magazine ad (specify):
Newsletter ad (specify organization):
Business/Networking Group:
E-mail blast (specify sender/group):

Page 1 of 5