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First Name (required)

Last Name (required)

Present Address (required)

City, Sate (required)

Years Lived Here (required)

Phone Number (required)

Alt. Phone Number

Email

Position Applying for: (required)

Why are you interested in this position? (required)

Please explain why you feel you are qualified to fulfill this position? (required)

Drivers License Number (The position you are applying for requires a Driver's License) (required)

Drivers License Class and Expiration Date (required)

Professional or Occupational Licenses or Certificates: (list any other relevant licenses or certificates (include tupe, description, issuing agency, etc.).

If hired, can you furnish proof of age and verification of your legal right to work in the United States? (required)Yes No

Do you have adequate transportation to and from work? (required)Yes No

Are you capable of performing the essential job duties required for the position for which you are applying, with or without accommodation? (required)Yes No

Have you ever used another name or alias? (required)Yes No

If yes, please list.

Other qualifications: Summarize special job related skills and qualifications acquired through prior employment or other experiences.

High School Education (Include School Name):

Years Completed:

Diploma/ Degree:

Course of Study:

Specialized Training/ Skills and Experiences:

College Education (Include School Name):

Years Completed:

Diploma/ Degree:

Course of Study:

Specialized Training/ Skills an Experiences:

Trade Education (Include School Name):

Years Completed:

Diploma/ Degree:

Course of Study:

Specialized Training/ Skills an Experiences:

Present or Last Employer:

Supervisor:

Phone Number:

Address:

Employment From:

Employment To:

Job Title:

Job Duties Performed:

Previous Employment:

Supervisor:

Phone Number:

Address:

Employment From:

Employment To:

Job Title:

Job Duties Performed:

Previous Employment:

Supervisor:

Phone Number:

Address:

Employment From:

Employment To:

Job Title:

Job Duties Performed:

Have you ever been terminated or asked to resign from any job? (required)Yes No

If yes, please give date(s) and provide details.

Please explain fully any gaps in your employment history.

May the District contact your current employer? (required)Yes No

If no, please explain why:

Please indicate any actual experience, special training and/or qualifications that you have which you feel are relevant to the position for which you are applying:

Please list any languages that you can read, write, or speak fluently:

Reference 1: Name (required)

Reference 1: Phone Number (required)

Reference 1: Relationship (required)

Reference 2: Name (required)

Reference 2: Phone Number (required)

Reference 2: Relationship (required)

Reference 3: Name (required)

Reference 3: Phone Number (required)

Reference 3: Relationship (required)

Resume (required)

APPLICANT'S STATEMENT & AGREEMENT In the event I am hired for employment with the Butte County Mosquito and Vector Control District (District), I will comply with all rules and regulations of this District. I consent to the disclosure of the results of any physical examination and related tests to the District. I understand and consent to the District’s contacting my previous employers listed on this application. I authorize those employers to disclose to the District all records and information pertinent to my employment with them excluding information regarding a protected status. I authorize the persons named herein as personal references to provide the District with any pertinent information they may have. I hereby state that all the information that I have provided on this application or any other documents completed in connection with my employment, and in any interview is true, accurate, and complete. I understand that if I am employed and any information provided to the District is found to be false or incomplete in any respect, I may be dismissed. I hereby state that I have read and understand the job description for the position that I am applying for and I understand that I must comply with all the requirements of the position, I can fulfill the physical requirements, with or without accommodation of the position, and I feel confident that I can meet the duties explained therein. If any term or provision, or portion of this Statement is declared void or unenforceable it shall be severed and the remainder of this Agreement shall be enforceable. If you have any questions regarding this statement, please ask a District representative before signing. I HEREBY ACKNOWLEDGE THAT I HAVE READ THE ABOVE STATEMENTS AND UNDERSTAND THEM. DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE "STATEMENT”Yes

Your Signature (required)

Confirm e-Signature

Review Electronic Records and Signatures Policy (required)

Read our Electronic Record and Signature Disclosure

I agree to use electronic records and signatures

Date

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The District has a policy of requiring a physician’s physical fitness exam, together with urine drug testing of persons who have been offered conditional employment.    If you are unwilling to consent to such an examination or test if offered conditional employment, it is recommended that you not submit an application.

All successful applicants are subject to a probationary period, in accordance with District Policy, Section 7005, Section 7005.6 and a pre-employment physicians’ urine and physical test in accordance with District Policy 7006. Copies of District policies are available at www.ButteMosquito.com.

"This institution is an equal opportunity provider and employer"