EMPLOYMENT APPLICATION FORM Name: Residence Address

An Equal Opportunity Employer and Provider
COALINGA-HURON
LIBRARY DISTRICT
EMPLOYMENT APPLICATION FORM
CONTACT INFORMATION
Applicants please provide all requested information.
Name:
Last
Residence Address:
First
Number and Street
City and State
Daytime Phone Number
Middle
Zip Code
Evening Phone Number
Position applying for:
PERSONAL INFORMATION
Applicants please provide all requested information.
Yes
No
If hired, would you have access to reliable transportation
to and from work?
Yes
No
Can you provide verification of your right to work in the U.S?
Yes
No
Do you speak, write and/or understand any foreign languages?
Yes
No
Yes
No
Are you 18 years of age or older?
(If under 18, hire is subject to verification that you are of minimum legal age.)
If yes, which languages?
Have you ever been convicted of a criminal offense (felony or
serious misdemeanor)?
(Convictions for marijuana-related offenses that are more than two years old need not be listed)
IF YES, state the nature of the crime, when and where convicted, and disposition of the case:
(No applicant will be denied employment solely on the grounds of conviction of a criminal offense. The nature of the offense, the
date of the offense, the surrounding circumstances and the relevance of the offense to the position(s) applied for may, however, be
considered.)
Coalinga-Huron Library District Employment Application Form
Rev. April 5, 2011
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EDUCATION
Please provide detailed information regarding your education.
Grade School and/or High School
Yes
No
Graduated from High School
Did not graduate; highest grade level completed:
Did not graduate but passed a GED (General Education Development) test
Name of School
Location
Higher Education (College, University, Vocational School)
Yes
Have vocational school degree
Have two-year accredited academic college degree
Yes
Do not have degree but
years from an accredited college/university
Yes
Have four-year accredited college/university degree
Yes
Have Master’s degree or Ph.D. from accredited college/university
School Name
Major
Did you
graduate?
Total
Units
No
No
No
No
Type of Degree
Received
SPECIAL REQUIREMENTS AND SKILLS
Please fill in this section if license(s), certificates, and skills are required for this position.
License, Certificate or Registration:
Has your license/certificate/registration ever been revoked or suspended?
Yes
No
If yes, state reason(s), date of revocation or suspension, and date of reinstatement:
Required Course Work:
Coalinga-Huron Library District Employment Application Form
2
Which online and/or automated systems have you worked with?
Dialog
RLIN
SIRSI
Innopac
Cir/CatPlus
Lexis/Nexis
InMagic/DBText
Dynix
Winnegago
OCLC
Athena
Other
Word
Excel
Access
PowerPoint
Publisher
Front Page
Print Master
Photoshop
Computer Skills:
Other
Please List:
WORK HISTORY
List below all present and past employment, starting with your most recent employer (last 10 years is
sufficient). Account for all periods of unemployment. You must complete this section even if
attaching a resume.
Company Name
Title or
Position
Dates of
Employment
Salary
Describe your responsibilities
Company Name
Title or
Position
# hrs
worked
weekly
Name and Title
of Supervisor
Reason for Leaving
Dates of
Employment
Describe your responsibilities
Coalinga-Huron Library District Employment Application Form
Salary
# hrs
worked
weekly
Name and Title
of Supervisor
Reason for Leaving
3
Company Name
Title or
Position
Dates of
Employment
Salary
Describe your responsibilities
Company Name
Title or
Position
Title or
Position
Name and Title
of Supervisor
Reason for Leaving
Dates of
Employment
Salary
Describe your responsibilities
Company Name
# hrs
worked
weekly
# hrs
worked
weekly
Name and Title
of Supervisor
Reason for Leaving
Dates of
Employment
Describe your responsibilities
Coalinga-Huron Library District Employment Application Form
Salary
# hrs
worked
weekly
Name and Title
of Supervisor
Reason for Leaving
4
WORK EXPERIENCE
Please check all areas in which you have work experience:
Reference
Cataloging
Indexing
Acquisitions
Online Searching
Technical Services
Periodicals
Collection Development
Records Management
Circulation
Web Page Design
Inter-Library Loans
Serials
Technical Reports
Classified Documents
Government Documents
Software Collections
Microforms
Standards
Fiscal Management/Budgeting
Other (list below*)
* Please list other work experience:
In which type of libraries have you worked?
Type of Work
Are you applying for:
Regular full-time work?
Yes
No
Regular part-time work?
Yes
No
Temporary work (e.g., summer or holiday)?
Yes
No
What days and hours are you available to work?
If applying for temporary work, during what period of time will you be available?
From:
To:
Are you available for work on weekends?
Yes
No
Would you be available to work overtime, if necessary?
Yes
No
If hired, on what date can you start work?
Salary desired
Coalinga-Huron Library District Employment Application Form
5
Have you ever applied to or worked for the Coalinga-Huron
Library District before?
Yes
No
Yes
No
If yes, when?
Do you have any friends or relatives working for the
Coalinga-Huron Library District?
If yes, state their name(s) and their relationship to you:
Relationship
Name(s)
Are you currently employed?
Yes
No
If so, may we contact your current employer?
Yes
No
Please explain any other experience, training, qualifications, or skills that you feel make you
especially suited for work at the Coalinga-Huron Library District:
READ THIS STATEMENT BEFORE SIGNING
Information provided on this application may be verified, including, but not limited to, contacting
former employers. My signature certifies that information on this application is true. I understand
and agree that any misstatements or omissions of material facts will cause forfeiture on my part
of all rights to employment by the Coalinga-Huron Library District.
Signature
Date
Note: Resumes will be accepted with a completed application form.
Submit by Email
Coalinga-Huron Library District Employment Application Form
6