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Personal Information

Date

Social Security Number

Californian Driver's License Number

Last Name

First Name

Middle Name

Last Name

First Name

Middle Name

Addresses

Street

City

State

Zip

Street

City

State

Zip

Residence Address for the past 5 years

To

From

Address

City

State

Zip

To

From

Address

City

State

Zip

From

To

Street

City

State

Zip

Phone numbers

Day-time number

Evening number

Employment desired

Date you can start

Position

What pay do you expect?

Your present employer?

If so, may we contact?

Are you employed now?

Are you available to work:

Education and skills

Language (1st)

Speak

Read

Write

Language (2nd)

Speak

Read

Write

Elementary School (name and location)

Years completed

High School (name and location)

Years completed

High school diploma

Undergraduate College/University (name and location)

Years completed

Degree/diploma name and classification

Graduate/Professional (name and location)

Years completed

Degree/diploma name and classification

Describe any specialized training, apprenticeship, skills or extra-curricular activities that are relevant to the job for which you are applying

Describe any honors, scholarships, appointments or awards that you have received:

State any additional information you feel may be helpful to us in considering your application:

List Professional, trade, business or civil activities and offices held. You may exclude information that would reveal sex, race, religion, national origin, age, ancestry, or disability or other protected status or personal information:

List any professional or vocational certificates, licenses, or registrations that you currently hold or have held in the past:

List any job-related professional or technical organizations to which you belong:

State

Number

Expiration date

Class

Restrictions or Suspensions (respond fully if driving is required by the job for which you are applying):

Additional information

U.S. Military or Naval Service?

Rank

Citations/awards

List any job-related skills that you learned while in the U.S. Military or Naval Service:

Are you over 18 years of age?

Have you been convicted of a crime? (Convictions will not necessarily disqualify an applicant from employment. Do not provide information about misdemeanor marijuana convictions more than 2 years old).

If yes, explain:

Have you used illegal drugs within the past three (3) weeks?

If yes, which illegal drugs did you use?

Are you currently under arrest for any crime, other than for possession of less than one ounce of marijuana more than two years ago, which has not been resolved (i.e., pending trial, etc.)?

Are you able to perform the duties of the position for which you are applying, including regular attendance?

Have you been discharged or asked to resign from a positions or a job?

If yes, explain reasons:

References

Referee Name (1st)

Address

Telephone number

Years acquainted

Referee Name (2nd)

Address

Telephone number

Years acquainted

Referee Name (3rd)

Address

Telephone number

Years acquainted

Former employers

Employer (1st)

From

To

Work performed

Address

Telephone number(s)

Starting

Final

Job title

Supervisor

Reason for leaving

Employer (2nd)

From

To

Work performed

Address

Telephone number(s)

Starting

Final

Job title

Supervisor

Reason for leaving

Employer (3rd)

From

To

Work performed

Address

Telephone number(s)

Starting

Final

Job title

Supervisor

Reason for leaving

Employer (4th)

From

To

Work performed

Address

Telephone number(s)

Starting

Final

Job title

Supervisor

Reason for leaving

Performance evaluations

Did you receive written performance evaluations from any of your prior employers?

Employer (1st)

Frequency of evaluations (e.g., annual, biannual, etc.)

Signed?

Employer (2nd)

Frequency of evaluations (e.g., annual, biannual, etc.)

Signed?

Employer (3rd)

Frequency of evaluations (e.g., annual, biannual, etc.)

Signed?

Explain any gaps in your employment history. (Do not provide information about any physical or mental disabilities or other medical information.)

In case of emergency notify:

Name

Phone No

Street

City

State

Zip

Declaration

I agree

Today's date

Print name