E - Person Centered Services E

First name*

Last name*

Middle name

Address*

City*

State*

ZIP

Position applying for

Phone*

Email*

What days and hours are you available to work?*

What date will you be available to start employment?*

How did you find out about this position?

Referred by a Current Employee

Other (please specify)

How did I find out about this position

Current Employee name

Check Yes or No to each of the following questions, explain when necessary

Are you over 18 years of age?*

Yes

Do you have a valid California driver’s license? (A current motor vehicle report may be required if driving is necessary for the position for which you are applying.)*

Yes

Can you provide proof after you are hired that you can legally work in the United States? (If hired, you will be required to submit proof of the legal right to work in the United States.)*

Yes

Can you, with or without accommodation, perform all of the essential functions of the job for which you are applying?*

Yes

Education/Training

Do you have a High School Diploma or Equivalent?*

Yes

Name and location of schools (high school, college, trade, business or correspondence)*

Name

Location

Graduate ?

Subjects Studied

Degree

Special Training: List any training you have had which may help to qualify you for the position for which you are applying. Include trade, vocation, military, etc. Indicate type of training, where acquired, dates and whether you completed it successfully.

Licenses/Certificates: List any licenses or certificates you have which my help to qualify you for the position for which you are applying. Include CPR, First Aid, Pro-Act, typing, software certificates, professional registration, etc.

Title

Date Issued

Date Expires

Languages you are proficient in:

EMPLOYMENT HISTORY

Employer’s Name

Your Title

Address

Phone number

Dates Employed (Mo/Yr)

From

Hours per Week

Supervisor's Name

May we contact? (Circle one)

Yes

Describe your duties

Reason for leaving

Employment history

List your entire work experience BEGINNING with your present or last job. Show promotions as separate jobs. Be sure to include appropriate military experience. If you need additional space, please supply all requested information on a separate sheet and attach to this application.

Please describe the following statement in your own words:

Please tell us about a situation in which you needed help solving a problem. What steps did you take to resolve the matter?‌

Give names of three professional persons not related to you, whom you have known for at least one year*

Name

Business Name

Relationship

Phone

File

Drop files here or

Max. file size: 50 MB.

The company may request personal character and investigative work history reports in connection with your application for employment or during the course of your employment (if any), with the company. Any information contained in such reports may be taken into consideration in evaluating your suitability for employment, promotion, reassignment or retention as an employee. Such reports, if obtained, will be prepared by a consumer reporting agency and may contain information concerning your credit standing or worthiness, character, general reputation, personal characteristics, or mode of living. The types of reports that may be requested, include, but are not limited to, medical examination, criminal records checks, court records checks, and/or summaries of educational and employment records and histories. The information contained in such reports may be obtained from public record sources or through personal interviews with your neighbors, friends, associates, current or former employers, or other personal acquaintances. My signature below authorizes this company to release the documents and their findings to its contractors Regional Centers of California.

I certify that the information contained in this application is true and correct and complete to the best of my knowledge and belief. I understand that any false statement, omission or misrepresentation of facts in connection with this application can be cause for rejection of my application, or if I am employed, for my dismissal from employment. I also understand that I am required to abide by all rules and regulations of the Employer.

I hereby understand and acknowledge that if I am employed, my employment relationship with the Employer is of an “at-will” nature, which means that I may resign at any time and the Employer may discharge me at any time, with or without cause. It is further understood that this “at-will” employment relationship may not be change by the President/CEO of the Employer.

Acknowledgement

I acknowledge that no other promises, agreements or representations have been made contrary to this “at-will” employment agreement, and that this agreement, as acknowledged by my signature below, is the full and complete agreement governing the Employer’s and my rights and obligations concerning termination of my employment.

Acknowledgment*

I agree

Signature

Applications will be maintained in an active file for a period of two years and then transferred to an inactive status for a period of one year from date received. We consider applicants for all positions without regard to race, color, religion, sex, national origin, age, sexual orientation, marital or veteran status, physical or mental disabilities, or any other legally protected status

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Name

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Person Centered Services

Application for Employment

Personal information

Check Yes or No to each of the following questions, explain when necessary

Education/Training

Employment history

Acknowledgement