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    Employment Declaration Form: County of Riverside Human Resources Department

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    sastecosto1
    This document is an employment declaration form for the County of Riverside Human Resources Department. It requests information such as the applicant's name, address, social security number, driver's license details, employment history including any relatives working for the county, and demographic information. The applicant must declare that all information provided is true and complete, and authorizes the county to verify the information. It is signed and dated at the bottom.

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

    Employment Declaration Form: County of Riverside Human Resources Department

    Uploaded by

    sastecosto1
    58 views1 page
    This document is an employment declaration form for the County of Riverside Human Resources Department. It requests information such as the applicant's name, address, social security number, driver's license details, employment history including any relatives working for the county, and demographic information. The applicant must declare that all information provided is true and complete, and authorizes the county to verify the information. It is signed and dated at the bottom.

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    Employment Declaration_1

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    This document is an employment declaration form for the County of Riverside Human Resources Department. It requests information such as the applicant's name, address, social security number, driver's license details, employment history including any relatives working for the county, and demographic information. The applicant must declare that all information provided is true and complete, and authorizes the county to verify the information. It is signed and dated at the bottom.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    58 views1 page

    Employment Declaration Form: County of Riverside Human Resources Department

    Uploaded by

    sastecosto1
    This document is an employment declaration form for the County of Riverside Human Resources Department. It requests information such as the applicant's name, address, social security number, driver's license details, employment history including any relatives working for the county, and demographic information. The applicant must declare that all information provided is true and complete, and authorizes the county to verify the information. It is signed and dated at the bottom.

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    COUNTY OF RIVERSIDE
    HUMAN RESOURCES DEPARTMENT
    EMPLOYMENT DECLARATION FORM

    Name (Last, First, Middle Initial) Social Security Number Telephone

    Physical Address (Street/P.O. Box, City, Postal Code

    Mailing Address if Different (Street/P.O. Box, City, Postal Code Driver's License Number, Class, and Exp. Date

    Department Position Title Employee ID (if available)

    Are you retired under the California Public


    Employees Retirement System (CalPERS)? No Yes

    Are you enrolled with the California Public Employees Retirement System
    (CalPERS) as a result of working for another CalPERS employer? No Yes

    List All Previous Names Under Which You Have Been Employed Language(s) other than English in which you are fluent:

    Employment of Relatives: No employee may execute direct supervision over or initiate or participate in decisions (including but
    not limited to initial employment, retention, evaluation, promotion, or work assignments) specifically pertaining to another County
    of Riverside employee who is related as spouse, father, mother, brother, sister, son, daughter, son-in-law, daughter-in-law,
    father-in-law, mother-in-law, brother-in-law, sister-in-law, or the equivalent through registered domestic partnership (County of
    Riverside Salary Ordinance, Ord. No. 440).
    List all close relatives, as defined above, and the Agency or Department in which they work. Do not specify the relationship.

    DECLARATION
    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 of Riverside and its agents to verify any information
    related to my Employment Declaration Form or continued employment with the County of Riverside and I authorize the release of
    any such information. I release the County and its agents from any and all liability for damage of whatever kind for seeking such
    information.

    Signature Date
    The information you provide in this section is voluntary and confidential. It will be used for statistical reporting only.
    Gender: Male Female Are you a Veteran of the United States Armed Forces with an honorable discharge having
    served during an expeditionary period or declared war? No Yes

    Ethnic/Racial Group (Indicate one with which you most closely identify):

    Hispanic or Latino White (Not Hispanic or Latino)


    Black or African American (Not Hispanic or Latino) Native Hawaiian/Pacific Islander (Not Hispanic or Latino)
    American Indian/Alaskan Native (Not Hispanic or Latino) Asian (Not Hispanic or Latino)
    Two or More Races (Not Hispanic or Latino)

    Rev. 12/1/2014

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