We consider applicants for all positions without regard to race, color, religion, sex, national origin, age, marital or veteran status, the presence of a non-job-related mental or physical disability, or any other legally protected status.
Check all that apply.
Proof of citizenship or immigration status will be required upon employment.
You may exclude memberships which would reveal sex, race, religion, national origin, age, ancestry, or handicap or other protected status.
Summarize special job-related skills and qualifications acquired from employment or other experience.
Having made an application for employment with the Chino Basin Water Conservation District (CBWCD), and desiring it to be informed as to my previous record and character, I hereby authorize any authorized representative of CBWCD, bearing this release, or a copy of it, within one year of its date, to obtain any information in your files pertaining to my employment, attendance, athletic, personal history, performance report, disciplinary records, including materials which may have been sealed and understood to be withheld pursuant to any prior agreement or court proceeding involving disciplinary matters, and credit records.
I hereby direct you to release this information upon request of the bearer. This release is executed with the full knowledge and understanding that the information is to be used only for the official use of CBWCD.
I hereby release you, as the custodian of such records, your employer, its officers, employees, or related personnel both individually and collectively, from any and all liability for damage of any kind, which may at any time result to me, my heirs, family or associates because of compliance with this authorization and request to release information, or any attempt to comply with it. Should there be any questions as to the validity of this release, you may contact me as indicated below.
I understand that I have the right to receive a copy of this authorization and acknowledge that I have received a copy of it.
4594 San Bernardino St
Montclair, CA 91763
This field is not part of the form submission.
* indicates a required field