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APPLICATION FOR EMPLOYMENT

Criminal background check, drug screen and motor vehicle report may be required of any candidate offered employment.

Contact Information
Name*
First Middle Last
Email*
Date*
Day Phone*
Evening Phone*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employment Desired
Position applying for
Full-time?*
- Yes
- No
Part-time?*
- Yes
- No
Temporary?*
- Yes
- No
*If yes to temporary, what period will you be available?*
Please list 'From/To' dates
What days and hours are you available for work?*
Monday: Tuesday: Wednesday: Thursday: Friday: Saturday: Sunday:
Are you available to work on weekends?*
- Yes
- No
Are there any hours you are unable to work?*
- Yes
- No
*If yes, what hours are you unable to work?*
If hired, on what date can you start work?*
Why are you applying for work here?*
Do you have any relatives or friends working here?*
- Yes
- No
If yes, state name(s) and relationship(s):*
Are you a member of the Habematelol Pomo of Upper Lake Tribe?*
- Yes
- No
If yes, provide your Enrollment Number:*
Are you a spouse or descendant of an enrolled member of the Habematelol Pomo of Upper Lake Tribe?*
- Yes
- No
Are you a tribal member of any other recognized tribe?*
- Yes
- No
If yes, state tribe name and Enrollment Number:*
Are you at least 18 years old?*
- Yes
- No
If hired, would you have a reliable means of transportation to and from work?*
- Yes
- No
Are you able to perform the essential functions of the job for which you are applying, either with or without reasonable accommodation?*
- Yes
- No
If no, describe the functions that cannot be performed:*
(Note: We comply with Federal, State and Local regulations and consider reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. Hire may be subject to passing a medical examination, and skill and agility tests.)

Education, Training & Experience

Note: You may need to provide a copy of a diploma, GED, and/or certifications.

High School
High School Name
Number of Years Completed*
High School Address
Street Address City State / Province / Region ZIP / Postal Code Country
Did you graduate?
- Yes
- No
Degree/Diploma?
- Yes
- No
College/University
College/University Name
Number of Years Completed
College/University Address
Street Address City State / Province / Region ZIP / Postal Code Country
Did you graduate?
- Yes
- No
Degree/Diploma?
- Yes
- No
Vocational/ Business/ Other
School Name
Number of years completed?
Other Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Graduated
- Yes
- No
Degree/Diploma?
- Yes
- No
Are you currently employed?*
- Yes
- No
May we contact your current employer?*
- Yes
- No
Do you have any other experience, training, qualifications, license, certification or skills that you feel make you especially suited for this position?*
- Yes
- No
If yes, please explain:*

Employment History

List below all present and past employment starting with your most recent employer. Account for all periods of unemployment. You must complete this section even if attaching a resume.
Employer's Name
Employer's Phone Number
Job Title
Supervisor's Name
Employer's Address
Street Address City State / Province / Region ZIP / Postal Code Country
Date Started
Month
Day
Year
Date Ended
Month
Day
Year
May we contact this employer for a reference?*
- Yes
- No
Job Responsibilities/Skills/Advancements
Reason for leaving
Employer's Name
Employer's Phone Number
Job Title
Supervisor's Name
Employer Address
Street Address City State / Province / Region ZIP / Postal Code Country
Date Started
Month
Day
Year
Date Ended
Month
Day
Year
May we contact this employer for a reference?*
- Yes
- No
Job Responsibilities/Skills/Advancements
Reason for leaving
Employer's Name
Employer's Phone Number
Job Title
Supervisor's Name
Employer Address
Street Address City State / Province / Region ZIP / Postal Code Country
Date Started
Month
Day
Year
Date Ended
Month
Day
Year
May we contact this employer for a reference?*
- Yes
- No
Job Responsibilities/Skills/Advancements
Reason for leaving
Employer's Name
Employer's Phone Number
Job Title
Supervisor's Name
Employer Address
Street Address City State / Province / Region ZIP / Postal Code Country
Date Started
Month
Day
Year
Date Ended
Month
Day
Year
May we contact this employer for a reference?*
- Yes
- No
Job Responsibilities/Skills/Advancements
Reason for leaving

References

List below two persons not related to you who have knowledge of your work performance within the last three years.
Full Name
Occupation
Phone Number
Years Aquatinted
Address
Street Address City State / Province / Region ZIP / Postal Code Country
Full Name
Occupation
Phone Number
Years Aquatinted
Address
Street Address City State / Province / Region ZIP / Postal Code Country

Upload Resume (Optional)
Drop files here or

Max. file size: 4 MB.
Acknowledgement & Consent
Acknowledgement*
In exchange for the consideration of my job application, I agree to the following:
I hereby certify that I have not knowingly withheld any information that might adversely affect my eligibility for employment and that the answers given by me are true and accurate. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement on this application or on any document used to secure employment shall be grounds for rejection of this application or termination of employment if employed, regardless of the time elapsed before discovery.

I hereby authorize Tribal Administration to thoroughly investigate my references, work record, education and other matters related to my suitability for employment and, further, authorize the references I have listed to disclose to Tribal Administration any and all letters, reports and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release Tribal Administration and my former employers from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure.

I understand that Tribal Administration has a drug and alcohol policy that provides for pre-employment testing as well as testing during employment; consent to and compliance with such policy is a condition of my employment; and continued employment is based on the successful passing of testing under such policy.

I also understand that, in connection with routine processing of the employment application, Tribal Administration may request from a consumer reporting agency an investigative consumer report. Upon written request from me, Tribal Administration will provide me with additional information concerning the nature and scope of any such report requested, as required by the Fair Credit Reporting Act.

I understand that Tribal Administration is an at-will employer and nothing contained in the application or conveyed during any interview which may be granted or during my employment, if hired, is intended to create an employment contract between me and Tribal Administration. In addition, I understand and agree that if I am employed, my employment is for no definite or determinable period and may be terminated at any time, with or without prior notice, at the option of either myself or Tribal Administration and that no promises or representations contrary to the foregoing are binding unless made in writing and signed by me and the designated representative.

I further understand that if I become employed by Tribal Administration, my employment shall be probationary for an introductory period of ninety (90) days. At any time during the probationary period or thereafter, my employment relation with Tribal Administration is terminable at will, for any reason by either party.

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.
Electronic Signature Consent*
As the applicant, I consent that by entering my name in the field below, I am signing this application electronically. My electronic signature is the legal equivalent of my manual signature on this application.
Electronic Signature*
Date*

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Upper Lake, CA 95485

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