APPLICATION FOR EMPLOYMENT
Delta Vector Control District
1737 W. Houston Ave – P.O. Box 310
Visalia, Ca.  93279 / 559-732-8606

Please print clearly, fill out form completely, sign and date.
Last Name                                                                                    First                                                                         Middle

Street Address
	Home Phone
                           	
City, Sate, Zip	Message Phone	
Position Desired	Email	
When will you be available for work?	Do you have a valid CA. driver’s license?       
                                                                          YES       NO 	
What type of employment will you accept?
                                                       FULL TIME     /    SEASONAL	Are you of the legal age to work?                      
                                                                          YES       NO	
Were you ever discharged or forced to resign from any position?
                                                                         YES      NO    
If yes, explain	Are you legally eligible for employment in the USA?
                                                                           YES      NO	
Do you have any physical conditions which may limit your ability to perform the job applied for?                               YES      NO	
Indicate any special qualifications or skills.

EDUCATION
School	Name & Location 
of school	Courses 
Studied	Did you 
Graduate? y/n	List
Degree	
Elementary					
High					
College					
Trade or Business					

REFERENCES
Give below the names of three persons not related to you, whom you have known at least one year.
Name	Address	Business	Years Known	

				

EMPLOYMENT HISTORY

Please give accurate, complete full-time and part-time employment record. Start with present or most recent employer.

Company Name	Telephone	
Address	Employed (State Month and Year)
From                               To	
Name of Supervisor	
State Job Title and Duties	
State reason for leaving	

Company Name	Telephone	
Address	Employed (State Month and Year)
From                               To	
Name of Supervisor	
State Job Title and Duties	
State reason for leaving	

Company Name	Telephone	
Address	Employed (State Month and Year)
From                               To	
Name of Supervisor	
State Job Title and Duties	
State reason for leaving	

In Case of emergency notify:  __________________________________________________________________________________
				Name				Address				Phone

Certification: “I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, false statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references listed above to give you any and all information they may have, personal or otherwise, and release all parties from all liability for any damage that may result from furnishing same to you.
I understand and agree that, if hired, my employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time without prior notice.”

DATE: ______________________________Signed: _______________________________________________