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2. Please Type What Position You are Applying For
4. First Name
5. Last Name
7. Address1
9. Address2
11. City
12. State
13. Zip
15. Home Phone
16. Work Phone
18. Email address
20. Have you ever worked for the City of Healdsburg?

    1. Yes
    2. No
21. Are you related to any person employed by the City of Healdsburg?

    1. Yes
    2. No
22. Are you a United States citizen, or an alien authorized to work in the United States?

    1. Yes
    2. No
24. Have you ever been convicted as an adult or any violation of the law?

    1. Yes
    2. No

    You should exclude all violations under $300 and those which have been expunged or otherwise removed from your record. Also, exclude any convictions more than two years old for violations of Health and Safety Code Sections 11357 (b) or (c), 11360 (b), 11364, 11365 and 11550 as related to marijuana offenses. A conviction is not necessarily a bar to employment and each case will be given individual consideration. A failure to list all convictions other than those excluded above, however, may disqualify you from further consideration.
25. If YES, please list offense(s) and date(s) convicted:
29. EDUCATION AND TRAINING
31. Do you have a high school diploma, GED, or California High School Proficiency Certificate

    1. Yes
    2. No
33. Name of College
34. Dates Attended
35. Couse of Study/Major
36. Degree Awarded

    1. Yes
    2. No
38. Type of Degree
39. Date Degree Completed
41. Name of College
42. Dates Attended
43. Course of Study/Major
44. Degree Awarded

    1. Yes
    2. No
46. Type of Degree
47. Date Degree Completed
49. Name of College
50. Dates Attended
51. Course of Study/Major
52. Degree Awarded

    1. Yes
    2. No
54. Type of Degree
55. Date Degree Completed
57. Other Relevant Courses and Training
58. Name and Location of Institution
59. Length of Course
61. Date Ended
63. Other Relevant Courses and Training
64. Name and Location of Institution
65. Length of Course
67. Date Ended
69. Professional License or Certificate, If Required
70. Serial No.
72. Date Issued
73. Expiration Date
75. Professional License or Certificate, If Required
76. Serial No.
78. Date Issued
79. Expiration Date
83. Drivers License No., Class and Expiration Date
84. Typing Speed (WPM)
85. Stenographic Speed (WPM)
87. Skills if required for position:
89. List any Foreign Language(s) in which you are fluent:
90. Other Skills
94. THIS SECTION MUST BE FILLED OUT
    You may attach a resume or other relevant documents to further describe your qualifications, however, a resume in-lieu of a completed application will not meet the requirement to submit a completed application
96. EMPLOYMENT HISTORY
    List your work record for the last 10 years. Begin with your most recent experience. Include self-employed and U.S Military service. Describe the work you did as completely as possible. List each promotion separately. Explain any gaps between employment periods.
98. Employer (Business Agency Name) and Address
99. Title of Your Position
101. Dates of Employment
102. Name of Supervisor
103. Supervisor's Phone No.
105. Hours worked per week
106. Salary: $
107. Reason for leaving
109. Duties
111. Employer (Business Agency Name) and Address
112. Title of Your Position
114. Dates of Employment
115. Name of Supervisor
116. Supervisor's Phone No.
118. Hours Worked Per Week
119. Salary: $
120. Reason for leaving
122. Duties
124. Employer (Business Agency Name) and Address
125. Title of Your Position
127. Dates of Employment
128. Name of Supervisor
129. Supervisor's Phone No.
131. Hours Worked Per Week
132. Salary: $
133. Reason for leaving
135. Duties
137. Employer (Business Agency Name) and Address
138. Title of Your Position
140. Dates of Employment
141. Name of Supervisor
142. Supervisor's Phone No.
144. Hours Worked Per Week
145. Salary: $
146. Reason for leaving
148. Duties
152. Were you ever discharged or forced to resign form any position?

     1. Yes
     2. No
154. If YES, explain
156. Inquiry may be made of your former employers or the last school you attended regarding your performance record. May we contact your present employer?

     1. Yes
     2. No
160. HOW DID YOU LEARN ABOUT THIS POSITION OPENING?

     1. City Bulletin Board
     2. City Employee
     3. Job Hotline
     4. Public Office other than City
     5. Minority Organization or Group
     6. Women's Organization or Group
     7. School
     8. Other
161. Newspapers

     1. Santa Rosa Press Democrat
     2. Marin Independent Journal
     3. San Francisco Chronicle/Examiner
     4. San Jose Mercury News
     5. Sacramento Bee
163. Other Publications

     1. Jobs Available
     2. Hispanic Careers Now
     3. Black Careers Now
     4. Asian Careers Now
164. Other (Please Specify)
Leave This Blank:


166. 1. Receive an email copy of this form.
167. Email address

     This field is not part of the form submission.

168. Submit

* indicates a required field