EMPLOYMENT APPLICATION

                                                                                                                                                                                   Date:                           
PERSONAL INFORMATION
 
FULL NAME:_____________________________________________________________________________________
			(Last)					(First)				(Middle)

  	_____________________________________________________________________________________
(State other names under which you have been educated or employed)

Address ________________________________________________________________________________________              _____________
		(Number)		(Street)			(City)			(State)			(Zip)

Home Phone ____________________ Cell Phone ____________________________ Email ___________________________________

Position applying for: ____________________________			What is your salary requirement? ______________________

What date will you be available to start employment: _________________________________ 

Will you accept:      Full time_____ Part Time_____ Temporary______ On Call_____ Night______ Weekends________
                                                                                                                                       _________________________________________
CHECK YES OR NO TO EACH OF THE FOLLOWING QUESTIONS. EXPLANIN WHEN NECESSARY

Are you over 18 years of age? (If no, a work permit or proof of emancipation will be required	[ ] Yes		[ ] No

Do you have a valid California driver’s license? 
(A current motor vehicle report maybe required if driving is necessary for the position for which you are applying.)	[ ] Yes		[ ] No

Have you worked for this healthcare district previously?		[ ] Yes		[ ] No

If employed in the position for which you have applied, would you be in a supervisory, subordinate, or co-worker (i.e. within same department) relationship to any relative or member of your household?		[ ] Yes		[ ] No

If “YES”, please specify: ____________________________________ (District policy may affect work assignment of related employees)

Have you ever been convicted of a criminal offense (felony or misdemeanor)? 	[ ] Yes		[ ] No
If “YES”, when, where and disposition of case: _______________________________________________________________________________________
(A conviction will not necessarily be a bar to employment-all factors involved will be considered.)

Can you, with or without accommodation, perform all of the essential functions of the job for which you are applying?
    [ ] Yes	[ ] No

Can you provide proof after you are hired that you can legally work in the United States?       [ ] Yes	[ ] No
 (If hired, you will be required to submit proof of the legal right to work in the United States)
______________________________________________________________________________________________________________________________________

EDUCATION

NAME	LOCATION	GRADUATE	SUBJECTS STUDIED	DEGREES	

					
SPECIAL TRAINING:  List any training you have had which may help to qualify you for the position for which you are applying.  Include trade, vocational, 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 may help to qualify you for the position for which you are applying.  Include driver’s license, ambulance endorsement, professional registration or certificates, etc

Title		State			Number				Date Issued		Date Expires

Languages which you can fluently: Speak__________________   Read_________________________	  Write__________________________

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.
.

Name of Employer

	What were your principal duties & title?	         Started work                                                Left work

MO                              YR                           MO                     YR	
Address of Employer

		Reason for Leaving?	
Telephone Number

Your Supervisor

		May we contact?

[    ] Yes                [   ] No	
Name of Employer

	What were your principal duties & title?	         Started work                                                Left work

MO                              YR                           MO                     YR	
Address of Employer

		Reason for Leaving?	
Telephone Number

Your Supervisor

		May we contact?

 [    ] Yes                [   ] No	
Name of Employer

	What were your principal duties & title?	         Started work                                                Left work

MO                              YR                           MO                     YR	
Address of Employer

		Reason for Leaving?	
Telephone Number

Your Supervisor

		May we contact?

 [    ] Yes                [   ] No	
Name of Employer

	What were your principal duties & title?	         Started work                                                Left work

MO                              YR                           MO                     YR	
Address of Employer

		Reason for Leaving?	
Telephone Number

Your Supervisor

		May we contact?

    [    ] Yes                [   ] No	

REFERENCES

NAME				ADDRESS				PHONE				REALATIONSHIP

The company may request consumer reports or investigative consumer 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, credit reports, criminal records checks, court records checks, and/or summaries of educational 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.

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 f acts 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 Employer may discharge me at any time, with or without cause.  It is further understood that this “at-will” employment relationship many not be changed by any statement of conduct of any person, unless such change is specifically acknowledged in writing, sign by the Chief of Operations/Board of Directors.

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 complete agreement governing the Employer’s and my rights and obligations concerning termination of my employment

Signature of Applicant____________________________________________________________		Date________________________

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 position 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.

Personnel:/employment application 7/2013