Application form

Applicant information

Last name

First name

Middle initial

Applied on

Street address

Apartment / Unit #

City

State

Zip

Contact phone

Alternative phone

Email

Are you legally eligible to work in the United States?

Yes

No

In compliance with federal law, all persons hired will be required to verify identity and eligibility to work in the United States and to complete the required employment eligibility verification document form upon hire.

Are you above the minimum working age of 18?

Yes

No

Are you related to any District employee?

Yes

No

If yes, give name and relationship

Have you ever worked for the District?

Yes

No

If so, when and in what position?

Have you ever been dismissed or released from employment or have you ever resigned to avoid discharge?

Yes

No

If “YES”, explain in detail

Do you have a valid driver's license?

Yes

No

State

License #

Expiration date

Education

High School

City

State

Graduate / G.E.D.

Yes

No

College

Address

From

To

Did you graduate?

Yes

No

Degree title

Job related license / certification

Number

Issuing body

Year issued

Fluency in languages other than English

Speaking

Reading

Writing

Experience

The following section must be filled out completely. Begin with your most recent job. List all jobs and any periods of unemployment in the last 10 years. Also list jobs prior to the last 10 years, including volunteer work, if the experience helps to qualify you for this position. Include paid or unpaid work, full or part-time, military, summer jobs, etc. Please attach additional sheets if necessary. Individual sections must be fully completed. A resume may be attached, but will not be substituted for completion of this section. Do not state, “see resume.”

From

To

Job title

Employer name

Address

City

State

Zip

Supervisor

Phone

Number supervised

Hours/week

Duties performed

Still working

Reason for leaving

References

Please list three references that are not relatives or former employers.

Full name

Phone

Address

Additional files

Select resume

Select cover letter

Select DMV printout

Waiver and signature

PLEASE READ THE FOLLOWING CAREFULLY BEFORE SIGNING AS IT CONTAINS IMPORTANT INFORMATION AND A WAIVER AND RELEASE OF LIABILITY.

I certify that all statements made in this application or other documentation submitted are true and complete to the best of my knowledge. I understand that any misstatement of material fact or omission of fact on my part will subject me to disqualification or dismissal if hired. I hereby authorize the Coachella Valley Mosquito and Vector Control District to investigate my ability, employment record, or character. I hereby release sources from any liability for any damages whatsoever for providing this information. I understand I will be required to submit copies of educational diplomas, transcripts, etc. when applicable. I am aware that any offer of employment is conditioned upon my ability to meet the established requirements of the job. I understand that as a condition of initial or continued employment, I agree to submit to such lawful examinations, (medical, drug screen, psychological or other), as may be required by the District. I understand that acceptance of an offer of employment does not create a contractual obligation upon the District to continue employment in the future.

I understand that all offers of employment are conditioned on my providing satisfactory proof of my identity and legal authority to work in the U.S.

Date

Please use your mouse or stylus to draw signature.

Electronic Signature - By clicking this box, you acknowledge you are signing this Application electronically. You further agree your electronic signature is the legal equivalent of your manual/handwritten signature on this Application.

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Employment application