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    DOT Employment Declaration Form

    Uploaded by

    vinod
    Employee declaration form

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    DOT Employment Declaration Form

    Uploaded by

    vinod
    17 views2 pages
    Employee declaration form

    Original Title

    DOT_Employment_Declaration_Form

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

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    Employee declaration form

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    17 views2 pages

    DOT Employment Declaration Form

    Uploaded by

    vinod
    Employee declaration form

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    RIVERSIDE COUNTY HUMAN RESOURCES

    EMPLOYMENT DECLARATION FORM

    Name (Last, First, M.I.): Social Security Number: Phone:

    Address (Street /P.O. Box / City/Zip): Position Title:

    Driver License Number (include class) & Expiration date: Languages other than English in which you are fluent:

    Have you ever been employed under another name? No Yes If Yes, Name:

    Are you retired under the Public Employees Retirement System (PERS)? No Yes

    List any close relatives, by blood, marriage, or adoption, working for the County. (This information is necessary to determine work assignments
    without conflict.) Name(s): Dept: Relationship:

    CONVICTION RECORD

    Due to the requirements of the position for which you are applying and/or probable assignment to a designated security risk area, you are asked to answer the
    following questions, then read and sign the statement at the bottom of this form. A records check may be conducted to verify the accuracy of your
    answers/comments.

    Have you ever been convicted of a felony? No Yes If Yes, provide date, location, and disposition of cases(s). Give as much information as
    possible. Use additional paper if needed.

    Date: Location: Charge: Sentence:

    DRUG & ALCOHOL TESTING RECORD (DOT regulated Safety Sensitive Positions ONLY)

    Due to the requirements of the Safety Sensitive Position in which you are applying for and in accordance with the Department of Transportation (DOT)
    Regulation 49 CFR Part 40, Section 40.25 you are asked to answer the following questions, then read and sign the statement at the bottom of this form. A drug
    & alcohol records check using former DOT regulated employers will be conducted to verify the accuracy of your answers/comments.
    Have you ever have an alcohol test with a result of 0.04 or higher in the last two (2) years? No Yes
    Have you ever had a verified positive drug test(s) in the last two (2) years? No Yes
    Have you ever refuse to take a drug or alcohol test from your employer(s) in the last two (2) years? No Yes
    Have you ever violated a DOT agency drug & alcohol regulation in the last two (2) years? No Yes
    Have your previous employer(s) ever reported a drug & alcohol rule violation on you in the last two (2) years? No Yes
    If you answered “yes” to any of the above items, did you complete the return-to-duty process during the last two (2) years? No Yes

    S:\DOT\Employment Declaration Form.doc:082399:103000 rev.


    By my signature below, I declare that all information provided on this Employment Declaration Form and all documentation submitted for employment to The
    County of Riverside is true and complete. I understand that falsification of information is grounds for disqualification, or termination if hired. I authorize the
    County and any of its agents to verify any information related to my Employment Declaration Form or continued employment with the County and I authorize
    release of any such information. I release the County from any liability for seeking such information.

    Signature: Date:

    The information you provide in this section is voluntary and confidential, and will be used for statistical reporting only.

    Are you a Veteran of the United States Armed Forces with an honorable discharge having served during an expeditionary period or declared war? Yes No
    Gender: Female Male Ethnic/racial group: Indicate one with which you most closely identify: American Indian/Alaskan Native Asian/Pacific Islander
    African-American Filipino Hispanic Caucasian

    S:\DOT\Employment Declaration Form.doc:082399:103000 rev.

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