Careers

General Data

Full Name

Have you ever used another name?

Yes

If yes, please specify for purposes of a reference check:

Address

Years at Above Address

Home Telephone Number

Position Applying For

Date of Application

Full Time or Part Time

Shift or Hours Preferred

Drivers License Number (if applicable)

Expiration Date

If employed in the position for which you have applied, would you be in a supervisory or subordinate relationship to any relative of your household?

Yes

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Personal Data

Person to notify in case of an Emergency (name):

Home Telephone Number

Emergency person's address

List membership in professional organizations which you feel would enhance your application. (You may exclude any whose names would indicate the race, religious creed, color, national origin, or ancestry of its members.)

If under 18 years of age, can you after employment, submit a work permit?

Yes

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Skills

Typing Speed (wpm):

Shorthand (wpm):

Machines Operated:

Other Training/Skills (include bilingual ability if relevant to the position for which you are applying):

Branch of Military Service:

State Dates: (From: To)

State relative skills acquired during military service:

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Professional & Technical Applicants Only

Professional License Number:

Expiration Date:

Type of License:

State:

Is there any reason why you would be unable to perform or to safely perform any of the duties of the position for which you have applied, as set forth on the job description for that position?

Yes

If “Yes,” please explain:

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Education

High School

Name

Address

Number of Years

Course or Major

Diploma/Degree

College

Name

Address

Number of Years

Course or Major

Diploma/Degree

Trade, Professional School, or Other

Name

Address

Number of Years

Course or Major

Diploma/Degree

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Work Experience

Employer

Address

Telephone Number

Supervisor's Name and Position

Your Job Title

Reason For Leaving

Length of Service Date (Start)

Length of Service Date (Leave)

Duties Performed

May we contact now? (If still employed)

Yes

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Criminal Record Statement

State law requires that person's associated with licensed facilities or Home Care Aide Registry applicants be fingerprinted and disclose any conviction. A conviction as any plea or guilty or nolo condendere (no contest) or a verdict of guilty. The fingerprints will be used to obtain a copy of any criminal history you may have.

Have you ever been convicted of a crime in California

Yes

You need to disclose any marijuana-related offenses covered by the marijuana reform legislation codified at Health and Safety Code sections 11361.5 and 11361.7.

Have you ever been convicted of a crime from another state, federal court, military or jurisdiction outside of U.S.?

Yes

Criminal convictions from another State or Federal court are considered the same as criminal convictions in California.

If you answer YES, give details on the back of this page indicating the nature and circumstances of each crime and the date and the location in which each crime occurred.

You must disclose convictions, including reckless and drunk driving convictions even if:

It happened a long time ago;
It was only a misdemeanor;
You didn't have to go to court (your attorney went for you);
You had no jail time or the sentence was only a fine or probation;
You received a certificate of rehabilitation;
The conviction was later dismissed, set aside or the sentence was suspended.

NOTE: IF THE CRIMINAL BACKGROUND CHECK REVEALS ANY CONVICTION(S) THAT YOU DID NOT DISCLOSE ON THIS FORM, YOUR FAILURE TO DISCLOSE THE CONVICTION(S) WILLRESULT IN AN EXEMPTION DENIAL, LICENSE APPLICATION DENIAL, LICENSE REVOCATION, OR EXCLUSION FROM A LICENSED FACILITY/ORGANIZATION.

I declare under penalty of perjury under the laws of the State of California that I have read and understand the information contained in this affidavit and that my responses and any accompanying attachments are true and correct.

FACILITY/ORGANIZATION NAME

FACILITY/GANIZATION NUMBER

YOUR NAME

YOUR ADDRESS

CITY

ZIP

SOCIAL SECURITY NUMBER

DATE OF BIRTH

DMV LICENSE NUMBER

DATE

I. Instructions to Respondents:

If you have been convicted of a crime in California, another state or in federal court, provide the following information:You need to disclose any marijuana-related offenses covered by the marijuana reform legislation codified at Health and Safety Code sections 11361.5 and 11361.7.

What was the offense?

In which state and city did you commit the offense?

When did this occur?

Tell us what happened.

I certify under penalty of perjury that the above information is true and correct to the best of my knowledge.

Yes

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Applicants Status

I hereby certify that I have been informed of the duties, the hours and days of work of the position for which I amapplying, and that the information on this application is correct and complete to the best of my knowledge.

I agree to have any of the statements checked by the Company unless I have indicated to the contrary. Further, I understand that falsification or omission of any material information on this application, if I receive a job offer, maybe considered sufficient cause for immediate termination. I agree that if employed, I will abide by all policies and procedures established by the employer.

I hereby acknowledge that my employment is ''at-will,'' that I may resign at any time and the Company may terminate my employment at any time, with or without cause, and with or without notice, that any assurances of continued employment, whether written, oral or by conduct, shall not be interpreted as changing the nature of the employment relationship unless specifically acknowledged in writing by the President of the Company

I agree

I do not agree

Work with us

General Data

Personal Data

Skills

Professional & Technical Applicants Only

Education

Work Experience

Criminal Record Statement

Applicants Status