Tribal Employment Rights Office

Tribal Employment Rights Office

Post Office Box 150 - Nespelem. Washington 99155

Ph. (509) 634-2716 Fax (509) 634-2740

TITLE 10, CHAPTER 10-3

FORESTRY CERTIFICATION APPLICATION

Business (Trade) Name:

Address (City, State, Zip Code)

Contact Person (Last, First, M.1.)

Business Phone: Business Fax Phone: E-mail Address:

Business Location:

Indian Traders License: Federal Id. No.

No. Of Employees: No. Of Indian Employees: Year Established:

Tribal Enrollment No.

BUSINESS STRUCTURE

An applicant seeking to qualify for preference in contracting and/or subcontracting as a 100% Colville Business

Enterprise, Colville Family Business Enterprise. Colville Business Enterprise. or other Indian Business Enterprise shall

submit proof of the applicant's Indian or Indian family ownership and control to the TERO office of the Tribes.

The following ownership and contro! requirements applicable to each preference category are as follows:

Please check the box you are applying for: (ONLY ONE PLEASE)

1. 100% Colville Business Enterprise:

A Ownership -- Enrolled Colville Tribal Members must own 100% of the firm.

B. Control -- Enrolled Colville Tribal Members must exercise 100% management and supervisory control of

the day-today operations of the business. All key employees must be Colville members

2. Colville Family Business Enterprise:

A. Ownership -- The firm must be 100% owned by a Colville member or a marital community consisting of

a Colville member and a non-Colville spouse.

B. Control -- The Colville member and their non-Indian spouse, parent or children must exercise 100%

management control and supervisory control of the day-to day operations of the business.

3. Colville Business Enterprise:

A. Ownership -- Enrolled Colville Tribal Members must own at least 60% of the firm.

B. Control -- Enrolled Colville Tribal Members must exercise majority control of the business and be

substantially involved in the day-to-day management and operations of the business.

4. Indian Business Enterprise

A. Ownership -- Indians must own at least 60% of the firm.

B. Control -- Indians must exercise majority control of the business. and be substantially involved in the

day-to-day management and operations of the business.

Revised 12.19.13 ep

A. 100% Colville Business Enterprise Applicants:

All firms applying for certification as a 100% Colville Business Enterprise must declare as follows:

Thereby declare under penalty of perjury under the laws of the Colville Tribes that: (1) ALL owners of

the business are Colville Tribal members. and (2) ALL employees of the business with management or

supervisory authority are Colville Tribal members.

Signature of Authorized Official

Print Name and Company Title

B. Colville Family Business Enterprise Applicants

All firms applying for certification as a Colville Family Business Enterprise must declare as follows:

I hereby declare under penalty of pergury under the laws of the Colville Tribes that: (1) ALL owners of

the business are Colville Tribal members or direct family members of Colville Tribal members. and (2) ALL

employees of the business with management or supervisory authority are Colville Tribal members or direct

family members of Colville Tribal members. (Direct family member is a spouse. parent or child.)

Signature of Authorized Official

Print Name and Company Title

C. Colville Business Enterprise or Indian Business Enterprise:

All firms applying for certification as a Colville Family Business or Indian Business Enterprise

must declare as follows:

Revised 12.19.13 cp

Les }

| hereby declare under penalty of perjury under the laws of the Colville Tribe that: (1) ONE or

MORE of the Indian owners must be substantially involved (as a senior level official), in the day-to-day

management and operation of the firm, and (2) Indians are employed in all or most of the positions for which

qualified Indians are available.

Signature of Authorized Official

Print Name and Company Title

CERTIFICATION

I hereby certify that the information provided in this application is true and complete to the best of my

knowledge and believe and agree to permit a credit check on the applying company.

1 understand that any false or misleading information furnished by me. on the Title 10. Chapter 10-3

Certification Application or in connection with this application for certification shall result in withdrawal of

my certification and | will be prohibited from applying for certification for one-year to date of withdrawn

application.

Name of Firm:

Signature of Authorized Official

Name: __

Title:

Enterprise or organization further states they will abide by Resolution 1998-852 and all provisions of the

Colville Tribal Code, Title 10.

Revised 12.19.13 ep 4

Enterprise or Organization:

The Colville Confederated Tribes T.E.R.O. has reviewed all documentation and application submitted on day of

.20__. The T.E.R.O. office is prepared to issue this notice as official certification for the above name

Indian owned enterprise or organization.

This firm is hereby certified as a:

Notary Public Date

Certification Approval Date T.E.R.O. Director

REISSUED OR REVIEWED INITIATED

Revised 12.19.13 ep 5

CERTIFICATION PROCEDURES*

New applicants tor Certification (firms not previously certified):

A firm seeking certification as a Colville Indian or Indian Business Enterprise shall submit a completed application to

the TERO on a form provided by TERO. TERO staff will be available to assist a firm in filling out the application,

request such additional information as it believes appropriate (computation of the 21-day period shall be stayed during

the time any request for additional information is outstanding ). conduct such investigations as it deems appropriate.

and make a final written finding to certify or not to certify. The TERO may extend the processing period by an

additional 21 days, by sending notification of the extension to the applicant by registered mail. Within 15 days of

receipt of the TEROMs analysis and finding. the applicant may request a hearing before the Commission on the

application to appeal any part of the certification finding. The Indian principal(s) of the firm shall be present at the

hearing. In addition, any person wishing to present information to the Commission shall be entitled to do so. by

requesting, no less than one day prior to the hearing. an opportunity to participate. Hearings shall be conducted as

provided for in CTC chapter 2-4.

Probationary Certification:

An applicant granted certification shall be issued a one-year probationary certificate. During that period, the TERO

statf and the Commission shall monitor the firm's activities to ensure that the firm is operating in the manner

described in its application. During the probationary period, the TERO and the Commission shall have the right to

request and receive such information and documents as they deem appropriate.

Final Certification

At the end of any probationary period the TERO. after receiving recommendations from the TERO Staff, shall either:

1. Grant full certification:

2. Continue the probationary period for up to six months: or

3. Deny certification

Withdrawal of Certification:

From the information provided in any required reports, on the basis of a written grievance filed by any other firm or

person. or on its own initiative, the TERO may initiate proceedings to withdraw or suspend the certification of any

firm. The TERO shall prepare an analysis and finding and prior to making a finding shall send the firm notice, by

registered mail, that its certification is being examined, along with the grounds therefore. A firm may appeal any

finding of withdrawal or suspension of certification to the Commission. which will hold a hearing. at which the TERO

shall have the burden of proof by the preponderance of the evidence, to determine whether the withdrawal or

suspension is justified. At the hearing, the TERO staff shall present the case for suspension or withdrawal, and the

firm shall have the opportunity to present evidence in support of their case. After the hearing. the Commission may:

. Withdraw certification

. Suspend certification for up to one year:

. Put the firm on probation: and/or

. Order that corrective action be taken within a fixed period. A firm that has had its

certification withdrawn may not reapply for a period of one year.

wl

Firms Certified Prior to the Adoption of These Criteria:

6

Each firm holding Indian preference certification from the Tribes prior to the effective date of this amended

Code shall submit an application required under these criteria to the TERO within 30 days after the effective

date of this amended Code. If the TERO determines that the firm qualifies under these new criteria, it shall.

within 45 days of receipt of the application, so find. Should the TERO require additional information from the

_ firm, computation of the 45-day period shall be stayed by written notice from the TERO for a reasonable time to

permit such information to be provided. If the TERO finds that certification is denied. the firm may appeal to

the Commission as set out above.

Change in Status and Annual Reports:

Each certified firm shall report to the TERO, in writing. any changes in its ownership or control status within

30 days after such changes have occurred. Each certified firm. on the anniversary of its receipt of permanent

certification, shall update the information provided in this initial application on an Annual Report form

provided by the TERO. Failure to provide information pursuant to these requirements shall constitute grounds

for TERO to move for withdrawal of certification.

INDIAN PREFERENCE**

All agencies and instrumentalities of the Confederated Tribes of the Colville Reservation shall give preference to

qualified Indian Business Enterprises when awarding contracts. Consistent with procedures and requirements

outlined in this section, preference shall be given in the following order:

1. 100% Colville Business Enterprises

2. Colville Family Business Enterprise

3. Colville Business Enterprises

4. Indian Business Enterprises

All Requests for Proposals, Invitations for Bids. or other contract solicitations shall contain a statement that Indian

preference applies in the award of the contract and in the work to be performed pursuant to the contract.

Confederated Tribes of the Colville Reservation

Tribal Employment Rights Office

Post Office Box 150 - Nespelem, Washington, 99155

Phone: 509-634-2716 / Fax: 509-634-2740

SMALL WORKS ROSTER

APPLICATION

Complete ALL Applicable Items

Please Print or Type

1. Business Name:

2. Address:

Street

City State Zip

3. Contact Person (1): (2)

4,

Business Phone Home Phone Fax Number

This section complete only if applicable —-

5. Washington State Contractor Registration Number

TET ETT et i tt

6 Social Security Number

TTT I-LEJ-LLi tT}

7. Are you a General or Specialty Contractor

General [ | Specialty [| FieldNo.{ | | | | | [ | | |

8. Are you a Certified Indian Owned Business’

Yes [| No [| Pending [|

9. Are you a Women Business Enterprise certified by the Washington State Office of Minority

and Women Business Enterprises?

CE] renting [7]

Yes [| No

10. Department of Revenue Excise Tax Number

LT T)-LETI-Li

Rev 12.19.13 ep

Fill in Codes In The Boxes & Circle Number

GENERAL & SPECIALTY CONTRACTORS:

Select up to Sixteen Specialties from the List below

Enter below the Two Digit Code(s) in the Boxes Provided Below:

Lj | | J tI} C1) C7

LT CE) CE) 9 a) Go oo Go

CODE DESCRIPTION & CS] NUMBERS CODE DESCRIPTION & CSI NUMBERS

49

Special Flooring (09700, 097-41)

O1 Roads & Bridges(small) (001002, 60200a, 002014) SG Special Coating (09800, 09875)

02 Demolition (02050, 02060) 3} Painting (09900, 09930)

03 Tree Service (02050. 02060) 32 Wall Covering (09950, 09900)

04 Structure Moving (02120) 53 Locks & Security Facilites (10000)

OS Pile Driving & Underpinning (021112, 02112. 02350) 34 Partitions | 10600. 10623)

05 Earth Work(02200. 02283. 02519) 38 Water Treatment

07 Sanitary & Storm Drainage (02400. 02434, 0272 1.02723) 56 Food Service Facilities (11400)

a7 Pre-engineer Structures (1312013125)

08 Irrigation Sprinkler System (024414, 02442) 38 Elevators, Lifts. Conveyers (14200. 14230)

09 Fencing (02444, 02446. 02.451) 02720)

10 Signs (02452, 10440) 59 Plumbing & Piping (15309, 15485, 62700, 14230)

11 Recreational Facilities (02462) 60 Fire Protection (15500. 15570. 13970)

12 Landscaping (02480, 02485) ol Boiler, Hot water, & Steam System (15600.

13° Asphalt Paving (02513) 18642. 18700, 15799)

14 Concrete (02515, 03000, 03603) 62 Refrigeration (15650, 15099)

15 Concrete Curbs (02528. 024294) 63 Heating. Venulation & Air Conditioning

16 Concrete Sawing, Drilling. Demolition (13800. 15895)

(03800, 03803a) 64 Controls & Instrumentation (15900, 15970,

17 Well Drilling & Casing (02730.02733) 16900, 16962)

18 Septic Tanks & Sewage Treatment (02740, 02743) 6S Electrical Wiring. Generation & Lighting

19 Marine Work (02880, 02890. 00202a) (16400. 16650, 00013a)

20 Dredging (02881) h6 Communication & Detection (16700, 16781)

21) Masonry (04200, 04451) 67 Solar Systems ( 10700}

22 Masonry Restoration & Cleaning 68 Siding

(03700, 03730, 04500. 04520) 69 Short Log Logging Trucks

23 Refactory Installation (04550, 04555) 70 Long Log Logging Trucks

24 Welding (05060) 7 Logging (Tractor-Cable-Mech. Harvester etc.)

25 Structural Metal Framing (05100, 05162) 72 Self Loader - Trucks

26 Metal Fabricators (05500, 05730) 73 Lowboy Trucks

7 Reinforcing Steel Placement (05602a} 74 Road Grading

28 Carpentry Rough/framing (05100. 05162) 78 Road Construction

29 Log Joinery 76 Water Truck (Pumper Truck,

30 Carpentry Finish & Cabinets (06260. 06240. 77° Super Train Logging Truck (Long Logs + Pup)

06400, 06431) 78 Harvest Operator

31 Water and Damp - Proofing (67100. 67193; 79° Wood Cutter

32 Insulation (07200, 07240, 00017) 80 Underground Uiihties (Telephone. TV. Power)

33 Fire Proofing (07250. 07260) 81 Flat Bed

34 Roofing-shingles (07300, 07322) 82 Electronic Medical Billing

35 Rooting-pretormed (07400, 07466) 83 General Billing and/or Collection

36 Roofing-membrane (0750.07460) 84 Clerical-General/Office Administration

37 Flashing & Sheet Metal (07600, 07661) 85 Tribal Contracting Process & Procedure

38 Door Installation (08100. 08450, 08721) 86 Pump Sales

39 Glazing/windows (08500. 08720, 08722. 8920) 87 Pump Installation

40 Plaster/lath (09200. 09225. 0001523 88 Pump Service

41 Drywall (09250, 00012a) 89 Water Pressure System

42 Tile (09300, 09380) 90 Underground Utilities (Telephone, TV. Power)

43 Terrazzo (09400, 09440) 9 Dump Truck

44° Acoustical Treatment (09500, 09530, 0001 1a) 92 Submersible Pump Installation for Water Wells

45 Wood Flooring (09550, 09595) 93 Chip & Sawdust Hauling

46 Stone & Brick Flooring (09600) 94 Tree Thinning

47 Resilient Floor (09650, 09675, 09750, 09758) us Stock Survey

48 Carpeting (09680, 09690)

Rev 12.19.13 cp

1], Please place a check by the location(s) you will work:

Entire State: __

Reservation Only: |

12. How many full-time employees do you currently have?

Q) 0-5 1 6-10 eb i-25 26-50. 51 or more

13. Below, please list your permanent employees. (Use another sheet if necessary)

Name Position Salary Years of

Service

a

14. — Below, please list your equipment. (Use another sheet if necessary)

Name Type Size $ Value Condition

Are you willing to rent your equipment?

Ys 8 No Q

15. Below, please list vour tools. (Use another sheet if necessary)

Name Type Size $ Value Condition

Are you willing to rent your tools?

No

Yes

Res 12.19.13 ep

GENERAL & SPECIALTY CONTRACTORS

Check box(s) that best describes the type of contract your firm qualifies to perform

+

~ ? Forestry

Electrical Wiring, Generation, & Lighting

Structure Moving

General

QO Self-loader | Masonry

0 Lowboy Carpentry

| Harvest Operator “Roofing

O Wood Cutter Cl] Drywall

O Tree Thinning _ Tile

QO Tree planting ‘J Flooring

Tree Marking O Carpeting ~

O Stand Exams © Painting

“Partitions

(| Locks and Security

(] Elevators, Lifts, & Conveyers

“Siding

Trucks Water Works

© Water/Pumper Truck | Well Drilling & Casing

O Flat Bed Co Septic Tanks & Sewage Treatment

QO Dump Truck CO Plumbing & Piping

(| Excavator () Boiler, Hot Water, & Steam System

(| Mini-Excavator C] Pump Installation & Service

Architecture Food Service

“Catering

(] Pre-engineer Structures Food Preparation

O Architect Services

Concrete/Welding Land

© Concrete | Earth Work

O Welding } Irrigation Sprinkler System

Ol Structural Metal Framing “Fencing

OC Flashing & sheet Metal “Landscaping

Electrical Construction

O Refrigeration Roads & Bridges

O Heating, Ventilation & Air Conditioning © Demolition

Solar Systems

Asphalt Paving

Road Grading

Road Construction

Other (please describe):

STEPS FOR OBTAINING AN INDIAN TRADER’S LICENSE:

1)

2)

3)

4)

5)

Get an Indian Trader’s License Application from Bureau of Indian Affairs- Colville Agency.

Complete pages 1 & 2, sign & date. Page 3 has to be completed only if you are a

corporate business.

You will need to provide the forms to Tribal Planning office for review of the business you are

proposing to determine compliance with tribal laws & business requirements and signature

approving applications.

Obtain a Money Order or Cashier Check for $5.00- made payable to the Bureau of Indian

Affairs or (B.I.A). Make sure to sign your name as the remitter of your money order, so

it can be tied back to your application.

Bring or mail completed application to:

BIA- Colville Agency

ATT: Indian Trader’s License

PO Box 111 (10 Nez Perce Street, bidg. 82)

Nespelem, WA 99155

Once the completed Indian Trader's License application, money order, and Tribal Planning

review sheet arrives at the BIA Superintendent's office, your Indian Trader’s License will be

generated and mailed to you at the address provided on your application (if not completed in

person).

PLEASE SEND A MONLY ORDER IN THE AMOUNT OF $5.00 PAYABLE TO THE BUREAU OF INDIAN AFFAIRS, WHEN YOU RETURN YOUR APPLICATION

INDIAN TRADERS LICENSE APPLICATION

NAME OF APPLICANT AND TRADE NAME, IF ANY

APPLICANT IS (CIRCLE ONE) = PROPRIETORSHIP PARTNERSHIP CORPORATION

iF APPLICANT IS A CORPORATION, LIST THE NAMES OF THE MEMBERS OF THE BOARD OF DIRECTORS. IF APPLICANT

1S A PARTNERSHIP, LIST THE NAMES OF ALL PARTNERS

ADDRESS OF APPLICANT

SITE OF PROPOSED BUSINESS

LIST THE CLASSES OF GOODS AND SERVICES TO BE SOLD

CAPITAL TO BE BORROWED (DEBT INVESTMENT) eS.

CAPITAL OWNED (EQUITY INVESTMENT) $

TOTAL CAPITAL TO BE INVESTED (TOTAL INVESTMENT) $

PROVIDE THE FOLLOWING INFORMATION CONCERNING ANY LOANS TO BE MADE TO FINANCE THE PROPOSED

BUSINESS

NAME OF LENDER

AMOUNT OF LOAN ; DATE DUE RATE OF INTEREST

NAME OF ANY ENDORSER OR SURETY

ATTACH TO THIS APPLICATION A COPY OF ANY CONTRACT OR TRADE AGREEMENT WITH CREDITORS OR

FINANCING INDIVIDUALS OR INSTITUTIONS. INCLUDING ANY STIPULATIONS WHEREBY FINANCING FEES ARE TO BE

PAID, REDUCE ANY ORAL AGREEMENTS ON THESE MATTERS TO WRITING AND ATTACH THEM TO THIS

APPLICATION.

ALSO ATTACH SCHEDULES “A” AND “B” AS REQUIRED.

| CERTIFY, that all of the statements made in this application are true, complete, and correct to the best of my

knowledge and belief and are made in good faith.

APPLICANT'S SIGNAURE (Sign in ink) DATE SIGNED

(If applicant is a corporation an authorized officer must sign.)

NAME OF CORPORATION PHONE NUMBER

SCHEDULE A

THIS SCHEDULE MUST BE COMPLETED BY THE FOLLOWING PERSON

1. A PERSON APPLYING AS A PROPRIETOR.

2. EACH PARTNER WHO IS LIABLE FOR THE DEBTS OF A PARTNERSHIP THAT IS APPLYING FOR A LICENSE.

3. THE PROPOSED BUSINESS MANAGER.

NAME OF PERSON COMPLETING THIS SCHEDULE

CIRCLE ONE: PROPRIETOR PARTNER BUSINESS MANAGER

DESCRIBE YOUR PRIOR BUSINESS EXPERIENCE (Attach additional sheets if necessary.)

WHERE HAVE YOU LIVED AND WORKED DURING THE PAST FIVE YEARS? (List most recent address first)

From ___To Address Occupation Employer’s Address

REFERENCES: List three persons who are NOT related to you and who have definite knowledge of your qualifications and

fitness to manage the proposed business. Do not list the names of supervisors on jobs held within the last five years.

FULL NAME PRESENT ADDRESS BUSINESS/ OCCUPATION

LIST THE NAME AND ADDRESS OF ANY BUSINESS YOU HAVE OWNED DURING THE PAST TEN YEARS.

HAVE YOU... YES NO

within the last five years been fired from any job for any reason?

within the last five years quit a job after being notified that you

would be fired?

Ever been convicted of an offense against the law or forfeited collateral,

or are you now under charges for any offense against the law? (You may

omit (1) traffic violations for which you paid a fine of $50 or less and

(2) any offense committed before your 21“ birthday that was finally

adjudicated in a juvenile court or under a Youth Offender law.)

IF YOUR ANSWER TO ANY QUESTION IN THIS SCHEDULE IS “YES”, GIVE DETAILS ON AN ADDITIONAL SHEET

ATTACHED TO THIS SCHEDULE.

| CERTIFY, that all of the statements made in this schedule are true, complete, and correct to the best of

my knowledge and belief and are made in good faith.

SIGNATURE (Sign in Ink) DATE SIGNED

SCHEDULE B

THIS SCHEDULE MUST BE COMPLETED BY ALL CORPORATE APPLICANTS

LIST THE NAME AND ADDRESS OF EACH RETAIL OUTLET OWNED OR OPERATED BY THE APPLICANT IN THE PAST

TEN YEARS

HAS ANY LICENSE TO DO BUSINESS HELD BY THE COPRORATION YES NO

BEEN REVOKED WITHIN THE LAST TEN YEARS?

IF THE ANSWER IS YES, GIVE DETALS CONCERNING EACH REVOCATION

ON ADDITIONAL SHEET ATTACHED TO THIS SCHEDULE.

ATTACH FINANCIAL STATEMENTS FOR THE CORPORATION PREPARED IN ACCORDANCE WITH GENERALLY

ACCEPTED ACCOUTNING PRINCIPLES COVERING THE PAST FIVE YEARS.

| CERTIFY that all of the statements made in this application are true, complete, and correct to the best of

my knowledge and belief and are made in good faith.

SIGNATURE OF AUTHORIZED OFFICER OF THE TITLE

APPLICANT CORPORATION :

NAME OF CORPORATION DATE SIGNED

NOTE: PLEASE INCLUDE A MONEY ORDER OR CASHIER’S CHECK FOR $5.00 MADE PAYABLE TO

THE BUREAU OF INDIAN AFFAIRS (BIA) WITH YOUR APPLICATION AND MAIL TO:

BIA- COLVILLE AGENCY

PO BOX 111

NESPELEM, WA 99155

APPLICATION FOR EMPLOYMENT

Colville Confederated Tribes & CTFC Enterprises

(Please Print All Information)

is complete and relevant to the job you are applying for. Applications will be kept on file for 3 months.

application to the appropriate enterprise, program or department on, or before, closing date as well as any required attachments. The |

Job Application alone does not determine if an applicant meets the minimum qualifications of a job, the interview process will determine |

if you successfully demonstrate the knowledge, skills or ability to meet the minimum qualifications. Please make sure your application |

NOTICE: Incomplete applications will not be accepted or processed. Applicant is responsible to submit a completed and signed |

|

i i i Date Received- b

Check Which Work Site(s) You Are Applying For Human Resources Dept |

[ ] Colville Tribes [ ] CTFC |

P.O. Box 150 Box 5, Birch St. Suite A

Nespelem, WA 99155 Coulee Dam, WA 99116

Phone: (509) 634-2842 Phone (509) 634-3200

Toll Free 800-506-9434 Fax (509) 634-3258

| Fax (509) 634-2864 [ ]CTSC[ ]MBC [ ]OBC []cDC

| | [ ] Gaming HQ

Personal Data

Last Name First Name M.I. Other Names/Alias Used

Mailing Address: Street/PO Box _City State Zip Code Telephone Number (Required)

Home:

E-Mail Address (optional) Message:

Employment Data

Position Applying For: Job Number: Department:

Are you claiming Indian preference? ENROLLMENT NUMBER - Valid proof of preference required

1.[ ] CCT Member 4.[ ] Other Tribe

2.[ ]CCT Descendent

3.[ ]CCT Spouse 5.[ ] Non-Indian

VETERAN’S PREFERENCE? : : Honorably

(For CCT positions only) Branch of Service Service Dates Discharged?

[ ]-Yes [ ]-No From: To: { ]Yes[{ ] No

| Education Background

|

List last high school attended. Beginning with the recent — list all colleges, vocational, and military service schools attended. * Please

_attach proof of certification from an accredited college for educational verification & educational consideration *

Do you have a High School Diploma | School Name Telephone Number

orGED? [ ] Yes [ ]No

Name & Location of School Graduate: Yes or No Major Course

College/University

College/University

Vocational/Technical School

Vocational/Technical School

List any specialized skills that you possess that will enhance your abilities to

perform in the following;

Specialized Skills/Training

Skills/Experience

Training

Certificates/Licenses

Accounting

Budget

Building Trades/Construction

Cash Handling

Child/ Early Childhood

Development

Clerical

(Typing/Filing/Phone/Office

Equip)

Computer (I/T)

Counseling

Culinary

Forestry, Wood Products

Gaming

(Be Specific)

General Labor

(Be Specific)

Health Care

Heavy Equipment

(Be Specific)

Maintenance

(Be Specific)

Management

(Be Specific)

Retail

Security

Supervision

(Be Specific)

| Work Experience

List most recent first. Lists only work history relevant to qualifications required for position applying for.

Do not leave any blank areas to avoid disqualification.

Employer Name

Address Phone:

| ()

Job Title: (Print) Start Date: End Date: | Reason For Leaving:

: ee — |

| Supervisor Name & Title: Start Wage End Wage Ay —

| | pepe , -YES |

$ $ Eligible For Rehire? [ ] -NO |

Provide a detailed description of the duties you performed, equipment operated, special skills gained,

etc. Use the back of this page if more space is required.

Employer Name Address Phone:

( )

Job Title: (Print) Start Date: End Date: Reason For Leaving:

Supervisor Name & Title: Start Wage End Wage

$ $ Eligible For Rehire? | | 7 hr°

Provide a detailed description of the duties you performed, equipment operated, special skills gained,

etc. Use the back of this page if more space is required.

Employer Name Address Phone:

( )

Job Title: (Print) Start Date: End Date: Reason For Leaving:

Supervisor Name & Title: Start Wage End Wage

$ $ Eligible For Rehire? | ]”\c°

Provide a detailed description of the duties you performed, equipment operated, special skills gained,

etc. Use the back of this page if more space is required.

Type License # es State Issued Expires

Driver's License

Flagger’s Card

Do you have any of the following Licenses/Permits?

Gaming [ ]Yes [ ]No | Bartender | [ ]-Yes [ ]-No

FoodHandler [ ]Yes [ ]No Child Care | [ ]-Yes [ ]-No |

| Legal [ ]Yes [ ]No Other, | [ ]-Yes [ ]-No

Have You Ever Had A License/Bond/Permit Listed Above Revoked or Suspended? | : i Ae

If YES, Explain: ,

Are you bondable? [ ]-YES [ ]-NO

Criminal History

Have You Ever Been Convicted of a Felony or Misdemeanor? | [ ]-YES [ ]-NO

You may be required to disclose the details of a “yes” response. Do you agree to provide this information as a condition

of consideration for hire?

[ ]-YES [ ]-NO

Employee Statement of Accuracy and Authorization To Obtain Background Information

| certify that all of the information given in this application is true, accurate, and complete. | understand any false or

misleading information, or incomplete information on this application may result in my not being hired, or my immediate

dismissal if | have been hired based upon any false or misleading information that | provided in this application.

| give my consent to the Colville Tribe Employer (Tribes, CTFC, or CTEC) to conduct an investigation into my

employment/work history and any pertinent information concerning my employment, criminal, financial and credit histories.

This is my authorization for any of my previous employers to release my employment history with them, including, but not

limited to, my performance level, attendance, and disciplinary records. | will hold harmless any previous employer for

releasing this information.

Applicant's Signature Affirming Above Statement Today’s Date

Are you 18 or

older?

[ ]-Yes [ ]-No

Last Name (Print) First Name MI Maiden Name

Topic Requiring Verification Comments:

Credit Background Check Verified

Criminal Background Clearance Verified

Driver’s License Verification

Drug Test Results Verified

Employment History Verified

Indian Preference Verified

License/Certification Verified

Veteran’s Preference Verified

Education Verified

Eligible for Hire[ ] YES [] NO

Other: |

For Official Use Only