Applicant Interest in Job Position(s): Date:
1. Social Security No: __________________________
2. CA Driver's License No.:_____________________
3.
CONTACT INFORMATION
Name: _______ Other names used: ________________
Address: City: Zip:
Day-Time Tel. No. Evening Tel. No.:_________________________________
LANGUAGE ABILITY
English: Speak Write
Spanish: Speak Write
Other:_________________ Speak Write
FINGERPRINT CLEARANCE
Upon employment state law requires that you be fingerprinted, and references must be checked.
REFERENCES
List personal references (not relatives) that known you for a minimum of five (5) years:
Name Occupation Address Phone Number
________
______
______
Plaza de la Raza Child Development Services, Inc. |
Plaza de la Raza Child Development Services, Inc.
Employment Application
Page 2
1. Are you related to any Plaza EMPLOYEE, BOARD MEMBER, and/or PARENT POLICY COMMITTEE MEMBER? ________ If yes, name and relationship
2. Do you have or ever had a child in our Program? _______, If so, indicate site location:_________________
3. Have you ever worked for this Agency? If so, in what capacity?
Location
4. Would you be interested in volunteer work at one of our centers?
If so, where
List any tickets or accidents that you have had within the past three (3) years ___________________
______
What office machines can you operate? ________
______
Typing speed WPM
A Regular Children's Center Permit is required for a teaching position. Attach a copy of your Permit to this application. Upon employment, the original Permit must be presented for verification.
Teaching and area aide positions: This agency encourages staff to attend school in order to improve performance and for advancement. Are you willing to take college classes while employed at this Agency?
Yes No
EDUCATION AND TRAINING
Name of High School
Address
Highest Grade Completed Year Diploma Yes No GED
College Location Major Units Comp. Date Degree
Number of Early Childhood Education units Number of General Education units
Are you currently taking classes or enrolled in school? Yes No
Name of Institution
Classes
List credentials, certificates, licenses, or permits you hold:
Name of Credential Type (Clear, Partial, etc.) Expiration Date
* Transcripts &/or permits for revelant position must be submitted with your application.
Plaza de la Raza Child Development Services, Inc.
Employment Application
Page 3
WORK HISTORY
List most recent position first. Indicate all work experience for at least the last ten (10) years. Attach additional sheets if necessary.
Do you give permission for us to contact your current employer? Yes No
Company/Agency Name From To
Complete Address
Position Ending Salary $ per week mo.
Job Description
Name and Title of Supervisor Telephone ( )
Specific reason for leaving
Company/Agency Name From To
Complete Address
Position Ending Salary $ per week mo.
Job Description
Name and Title of Supervisor Telephone ( )
Specific reason for leaving
Company/Agency Name From To
Complete Address
Position Ending Salary $ per week mo.
Job Description
Name and Title of Supervisor Telephone ( )
Specific reason for leaving
Plaza de la Raza Child Development Services, Inc.
Employment Application
Page 4
PERSONAL STATEMENT
(Please complete in your own handwriting)
Write a brief essay as to why you feel you qualify for the position you are applying for (talk about your experience, skills and training acquired).
LIC 508 910/83
Have you ever been convicted of a crime? (Exclude any minor traffic violations for which the fine was $50 or less), or are you currently under indictment? Yes No
If yes, attach a signed statement indictment the nature and circumstances of the crime(s).
I declare under penalty of perjury that I have read and understand the information contained in this affidavit and that my responses and accompanying attachments are true and correct. Any deliberately false statement will result in my disqualification for consideration for employment or discharge by the agency.
Signature County Where Signed Date
THIS APPLICATION WILL REMAIN IN THE ACTIVE FILE FOR 120 DAYS
For positions in the bargaining unit (non-supervisory personnel) employee shall join CFT, Local 1475, upon completion of probation.
Revised Jan 2008 SRM
Plaza de la Raza Child Development Services, Inc.
Employment Application
Page 5
REFERENCE CHECK AUTHORIZATION
Employment with Plaza de la Raza Child Development, Inc. is contingent upon Policy Committee approval, ability to meet medical standards, criminal record clearance and other requirements applicable to the position desired. Until all employment procedures are satisfied, any offers of employment are conditional and preliminary and may be withdrawn at any time.
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The information I have provided in this Application for Employment is true, and correct and complete. False, incomplete or misrepresented information of any kind will be sufficient cause for my application to be rejected or, if discovered after I am employed, cause for immediate termination of my employment.
I authorize the employer to contact and obtain information about me from previous employers, educational institutions and "references" I provided, and any other party necessary to verify the accuracy of information I disclosed in this application, a related employment resume or personal interview. To assist in the processing of my Application, I waive all rights and claims I may otherwise have against the employer or its representatives, for seeking, and using information to evaluate my employment request and all other persons, corporations or organizations who provide information for this purpose.
This application is not an employment agreement. If I accept an offer of employment, I understand I may resign at any time, and the employer may terminate my employment at any time with cause and due notice, unless required by law. I understand that no one has authority to enter into any employment agreement with terms contrary to the foregoing unless made in writing and signed by the employer's designated officer.
I FULLY UNDERSTAND AND ACCEPT ALL TERMS AND CONDITIONS IN THE ABOVE STATEMENT.
______________________________ _________________________________
SIGNATURE DATE
