Humboldt Transit Authority
Application for Employment
133 V Street
Eureka, CA 95501

An Equal Opportunity Employer

Please type or print in dark ink. Use additional pages if necessary

Title of Position Applied For:

Bus DriverMechanicOther
Last NameFirstMiddle
AddressCityStateZip Code
Home PhoneWork/Message Phone

Check “Yes” or “No” to each question below. Explain “Yes” answers

Are you now or have you ever been an employee of the Humboldt Transit Authority?

Yes   No            If yes, state position and dates of employment.

______________________________________________________________________________

Are you related to anyone now employed by the Humboldt Transit Authority?

Yes   No            If yes, state name and relationship.

______________________________________________________________________________

Have you ever tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which you applied, but did not obtain the position in the past two years?

Yes   No        If yes, state employer name and address.

______________________________________________________________________________

Are there any hours/days you cannot work, or is there any reason you cannot accept part-time employment?   Yes    No

______________________________________________________________________________

When will you be available for employment?                                                               
______________________________________________________________________________

List the name, address, and telephone number of three persons living in the United States who are not related to you and who have definite knowledge of your qualifications for the position you are applying for:

1 ______________________________________________________________________________                                                                                                                                                       

2  ______________________________________________________________________________                                                                                                                                                      

3  ______________________________________________________________________________                                                                                                                                                      

Are you a high school graduate or do you possess a GED?
Yes   No           

Colleges attended, if any. List name, location, dates, major, units, and degrees.

1. ______________________________________________________________________________                                                                                                                                           

2.

______________________________________________________________________________

3.

______________________________________________________________________________

If the job you are applying for requires specific skills, describe your proficiency in those skills:
______________________________________________________________________________

______________________________________________________________________________

State any licenses or certificates you hold which may help to qualify you for the position you are applying for. This includes driver licenses, professional registrations, certificates, etc.

______________________________________________________________________________

______________________________________________________________________________

Describe any training you have had which may help to qualify you for the position you are applying for. This includes training in trade, vocational, and business schools and manpower training programs. State type of training, where received, dates and whether successfully completed.

______________________________________________________________________________

______________________________________________________________________________

May Humboldt Transit Authority contact your current employer if you are considered for a job offer?

Yes   No            If no, explain why:
______________________________________________________________________________

______________________________________________________________________________

List your work experience, beginning with your current or most recent employer, in reverse order. Show promotions as separate jobs. Include appropriate military experience. IMPORTANT: Check box* if this job gave you experience applicable to the position you are now applying for.

Employer:
*
Address:
Telephone Number(s):
Job Title:
Supervisor:
Reason for Leaving:
Dates Employed:
From:
To:
Work Performed:
Employer:
*
Address:
Telephone Number(s):
Job Title:
Supervisor:
Reason for Leaving:
Dates Employed:
From:
To:
Work Performed:
Employer:
*
Address:
Telephone Number(s):
Job Title:
Supervisor:
Reason for Leaving:
Dates Employed:
From:
To:
Work Performed:
Employer:
*
Address:
Telephone Number(s):
Job Title:
Supervisor:
Reason for Leaving:
Dates Employed:
From:
To:
Work Performed:

NOTICE: You may be required to submit proof that you meet legal age, licensing and right to work requirements before appointment to any position. If you are selected for employment you will be medically examined at the expense of Humboldt Transit Authority.

If you disagree with the results of that examination, you may,
 at your own expense, submit independent medical opinions for consideration before any final determination on disqualification is made.


I understand that my employment to Humboldt Transit Authority is contingent on passing a drug test.



READ CAREFULLY BEFORE SIGNING: I certify that all statements made in this Application are true to the best of my knowledge.  I understand that false statements or omissions of material fact shall be sufficient for dismissal or disqualification from employment.

Signature:____________________________________________________________________
Date:_________________________________________________________________________

OFFICE USE ONLY:

Application Received on: ______________________________________
By:______________________________________________________________