THIS PAPER CONTAINS IMPORTANT …countyconnection.com/wp-content/uploads/2010/06/Administration...Please advise Human Resource personnel prior to the ... PERIODS OF EMPLOYMENT ...

County Connection administrative job category includes all clerical, administrative, supervisory

and management positions. Many of the upper-level vacancies are filled through internal

promotion of County Connection employees.

To be considered for employment with the Administration Department at County Connection, all applicants must meet the following minimum requirements:

1. Your application must be legible and complete.

2. You must possess the skills and work experience necessary to the particular position forwhich you are applying.

3. Most positions require that you be able to read, write, speak and understand English.

4. You must have a stable, verifiable job history.

5. You must not have had any job-related criminal convictions within the past ten years.

6. To promote employee and public safety and a drug-free environment, you must pass apre-employment urine drug screen for illegal substances. County Connection is alsorequired by federal mandate to conduct random selection testing on certainadministrative employees.

If we have a vacant position for which we feel you may be qualified, we will contact you to

schedule any necessary tests or interviews. If we do not have a suitable opening, we will hold

your application for future consideration.

Employment applications are kept in our active files for one (1) year. Please advise us if your

address or telephone number changes within that time. Our contact information is below:

County Connection 2477 Arnold Industrial Way, Concord, CA 94520

(925) 676-1976

Thank you for your interest in County Connection.

THIS PAPER CONTAINS IMPORTANT INFORMATION. PLEASE READ IT CAREFULLY BEFORE COMPLETING AN APPLICATION.

Updated 04/17

CENTRAL CONTRA COSTA TRANSIT AUTHORITY IS AN EQUAL OPPORTUNITY EMPLOYER

PLEASE READ CAREFULLY This is a confidential employment application. Please answer all questions as completely and accurately as possible. Failure to

complete this form thoroughly may result in disqualification of your application. If a question does not apply, put N/A (not applicable)

in the place of an answer.

PLEASE PRINT IN INK OR TYPE

Name (First, M, Last) Date

Street Address I am available to work: (check applicable boxes)

Full-time

Part-time Days/hours available:_______________

Either Full-time or Part-time

Regular

Temporary – For how long? ___________________

Either regular or temporary

Days available to work:

Monday Tuesday Wednesday

Thursday Friday Saturday Sunday

Shift(s) available to work:

Day Swing Grave

Available for overtime? Yes No

City State Zip

Home Phone Cell Phone

If hired, can you furnish:

(a) Proof of age over 17? Yes No

(b) Proof of U.S. Citizenship or

authorization to work in the U.S.? Yes No

Position(s) applied for:

Salary required: Date available for work:

CCCTA is required by Federal mandate to perform drug and

alcohol tests on all employees performing safety sensitive

functions. This includes random selection testing.

The hiring process may involve interview(s), timed written

test(s) and job demonstration(s). Please advise Human

Resource personnel prior to the interview or test if you need

a reasonable accommodation for this process.

CCCTA policy generally restricts concurrent employment

of immediate family members of employees, consultants

or board members. Immediate family includes spouse,

children, parents, grandparents, brother, sister, or legal

guardian, and the children, parents, grandparents, brother,

sister, or legal guardian of the spouse.

Does CCCTA currently employ any of your immediate

family as defined here? Yes No

Have you ever applied to CCCTA previously? Yes No

If yes, when? _____________________________________

________________________________________________

Have you ever been convicted of a felony, or within the last

ten (10) years, a misdemeanor? Yes No

(If yes, please provide details ON AN ATTACHED SHEET)

Have your ever worked here? Yes No

If yes, When? ___________________________________

Where did you hear about this position?

Employee Friend Relative Unemployment

Newspaper ________________________(Which one)

Other ____________________________(Please state) Updated 04/17

EMPLOYMENT HISTORY List your employment experiences for the past ten (10) years starting with the most recent. ACCOUNT FOR ALL

PERIODS OF EMPLOYMENT AND UNEMPLOYMENT. Include any significant volunteer experience, military service

and education. Complete this section even if you attach a resume.

In order to verify employment experience, may we contact your current employer? Yes No

1 Name of Company Phone Number Mo/Yr Hired Mo/Yr Left Starting Salary Ending Salary

Street Address Title of your starting position Title of your last position

City State Zip Description of duties of your last position

Your name while there

Name of Supervisor

Supervisor’s Phone Number

Reason for leaving

2 Name of Company Phone Number Mo/Yr Hired Mo/Yr Left Starting Salary Ending Salary

Street Address Title of your starting position Title of your last position

City State Zip Description of duties of your last position

Your name while there

Name of Supervisor

Supervisor’s Phone Number

Reason for leaving

3 Name of Company Phone Number Mo/Yr Hired Mo/Yr Left Starting Salary Ending Salary

Street Address Title of your starting position Title of your last position

City State Zip Description of duties of your last position

Your name while there

Name of Supervisor

Supervisor’s Phone Number

Reason for leaving

4

Name of Company

Phone Number

Mo/Yr Hired Mo/Yr Left Starting Salary Ending Salary

Street Address

Title of your starting position Title of your last position

City State Zip Description of duties of your last position

Your name while there

Name of Supervisor Supervisor’s Phone Number

Reason for leaving

IF YOU HAVE HAD MORE THAN FOUR (4) EMPLOYERS IN THE LAST TEN (10) YEARS, PLEASE REQUEST AN ADDITIONAL PAGE.

If any periods of time are not covered by the information above, please provide dates and details:_____________________________________________

Have you ever been involuntarily separated (fired)? Yes No If yes, please provide details:___________________________________________________

Updated 04/17

SKILLS/KNOWLEDGE/EDUCATION

PLEASE COMPLETE SECTIONS WHICH APPLY TO THE POSITION(S) YOU DESIRE

CLERICAL POSITIONS ONLY Indicate your skills, equipment knowledge or education. (CHECK AS MANY AS APPLY)

Typing _____ WPM

Shorthand _____ WPM

Dictaphone

Clerical Classroom Training-School (Name & Address): __________________________________________________________

Dates - From: _____________ To: ____________ Certificate received? Yes No Type:_________________________

Word Processor – Please state brands: ________________________________________________________________________

Other (please describe): ___________________________________________________________________________________

DRIVER/MECHANIC/SERVICE WORKER POSITIONS ONLY The California Department of Motor Vehicles requires that applicants for the Class B driver’s license have successfully completed the Federal Department of

Transportation Medical Examination. Would you consent to this exam at CCCTA’s expense? Yes No

Have you ever had a job that involved driving? Yes No If yes, what type of vehicle?__________________ Number of years of employed driving experience: ______________

Has your driving license ever been revoked or suspended? Yes No If yes, please explain:

Do you have valid California driving license? Yes No License Number: ______________________ Expiration Number:_____________________

Class C Class B Class A

Are there any restrictions on your driving license? Yes No If yes, please state restriction(s):

How many moving violations have you received in the last five years? ________________________________________________________

How many traffic accidents have you been involved in during the last five years? _________________________________________________________________

MECHANIC/SERVICE WORKERS POSITON Have you ever had a job that involved mechanical repair of a diesel vehicle?

Yes No If yes, what type of vehicle(s)?________________________

Do you have your own tools? Yes No If yes, which types? _______________________________________________

Have you taken mechanics vocational training? Yes No Name of course: ______________________________________________

Certificate received? Yes No What type? __________________________________________________

School (name & address): _______________________________________________________________ _______________________________________________________________ Dates - From:_____________________ To:____________________________

GENERAL INFORMATION

Please indicate below any other information which you feel may qualify you for the type of work desired.

PLEASE READ CAREFULLY BEFORE SIGNING I certify that the information given by me in this application is true and complete. I understand and agree that any false information, misrepresentation, omission, or concealment of fact is sufficient grounds for either my immediate discharge without recourse or refusal of employment by CCCTA. I fully understand that if I am not bondable by a surety company, CCCTA may be unable to offer employment. I understand and agree that all information furnished in this application may be verified by CCCTA. I hereby authorize all individuals and organizations named or referred to in this application and any law enforcement organization to give CCCTA all information relative to my employment, work habits and character and herby release such individuals, organizations and CCCTA from any liability for any claim or damage which may result. Signature:_______________________________________________ Date:______________________________________

Updated 04/17

01/2016

CENTRAL CONTRA COSTA TRANSIT AUTHORITY APPLICATION

EQUAL EMPLOYMENT OPPORTUNITY SURVEY

CONFIDENTIAL

Please complete this survey and submit it with your application for employment. Federal and State agencies

require that we collect the data which is requested below for statistical reporting purposes in connection with our

affirmative action efforts. Your completed survey form will be detached from your application for employment

and kept separate and confidential in the Authority’s EEO Office. The information requested here will not be

used in any discriminatory manner. You are not required to complete this form to be considered for employment.

However, the information you provide will be most helpful and appreciated.

Position: ______________________________________________

Name: ________________________________________________

Date of Birth: ________________________ Male: ______ Female: ______

DISABILITY and MILITARY SERVICE (Please complete if applicable) Are you disabled? Yes _____ No ______

(A person with a disability is defined as an Individual who (1) has a physical or mental impairment that substantially limits one or more of his/her major life activities; (2) has a record of such an impairment; or (3) is regarded as having an impairment.)

Are you a Veteran? Yes ______ No ______

If yes, indicate dates of service: From ______ To ______

ETHNIC BACKGROUND (Please check only one) ____ HISPANIC or LATINO: A person of Cuban, Mexican, Puerto Rican, South or Central

American, or other Spanish culture or origin regardless of race. ____ WHITE (Non-Hispanic or Latino): All persons having origins in any of the original peoples of Europe, North Africa, or the Middle East. ____ BLACK or AFRICAN AMERICAN (Non-Hispanic or Latino): A person having origins in any of the Black racial groups of Africa. ____ ASIAN (Non-Hispanic or Latino): A person having origins in any of the

original peoples of the Far East, Southeast Asia, the Indian Subcontinent, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

____ NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER (Non-Hispanic or Latino): A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

____ AMERICAN INDIAN OR ALASKA NATIVE (Non-Hispanic or Latino): A person having origins in any of the original peoples of North and South America (including Central America), and who maintain cultural identification through tribal affiliation or community attachment.

____ TWO OR MORE RACES (Non-Hispanic or Latino): All persons who identify with two or more racial categories named above. ____ DECLINE TO STATE

Signature: ____________________________________ Date: ________________________ Updated 04/17