Form LIC 501 Personnel Record - California

Form LIC501 is a California Department of Social Services form also known as the "Personnel Record". The latest edition of the form was released in March 1, 1999 and is available for digital filing.

Download a fillable PDF version of the Form LIC501 down below or find it on California Department of Social Services Forms website.

ADVERTISEMENT
STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
DATE
PERSONNEL RECORD
(Form to be completed by employee)
NAME OF FACILITY
FACILITY ADDRESS
FACILITY FILE NUMBER
1.
PERSONAL
TELEPHONE
NAME (LAST
FIRST
MIDDLE)
(
)
ADDRESS
ARE YOU 18 YEARS OF AGE OR OLDER?
YES
NO
IF NO, PLEASE STATE YOUR AGE
_____________________________
SOCIAL SECURITY NUMBER: (VOLUNTARY FOR ID ONLY)
DATE OF LAST PHYSICAL EXAMINATION
DATE OF LAST TB TEST
-
-
HAVE YOU EVER BEEN EMPLOYED UNDER A DIFFERENT NAME?
YES
NO
IF YES, PLEASE LIST ALL NAMES USED.
DO YOU POSSESS A VALID CALIFORNIA DRIVER'S LICENSE?
YES
NO
HAS YOUR DRIVER'S LICENSE EVER BEEN SUSPENDED OR REVOKED?
YES
NO
CDL NUMBER
IF YES, PLEASE EXPLAIN ON BACK OF FORM.
NEAREST LIVING RELATIVE — NAME:
TELEPHONE NUMBER
RELATIONSHIP
ADDRESS
2.
POSITION
TITLE
SALARY
HOURS
DATE OF EMPLOYMENT
NAME OF SUPERVISOR
3.
PREVIOUS EMPLOYMENT
(List most recent experience first. If additional space is needed, please attach a separate page.)
TELEPHONE
JOB TITLE AND
DATES
REASON FOR
NAME AND ADDRESS OF EMPLOYER
NUMBER
TYPE OF WORK
FROM
TO
LEAVING
4.
EDUCATION
CIRCLE HIGHEST YEAR COMPLETED
DIPLOMA
CURRENTLY ENROLLED IN HIGH SCHOOL COMPLETION COURSE?
6
7
8
9
10
11
12
NO
YES IF YES, GIVE EXPECTED COMPLETION DATE___________________
EMPLOYMENT — RELATED EDUCATION COURSES
NUMBER
NAME OF SCHOOL OR ORGANIZATION
CURRENTLY
DATE
UNITS
COURSE TITLE
AND ADDRESS
ENROLLED
COMPLETED
COMPLETED
LIC 501 (3/99)
(OVER)
STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
DATE
PERSONNEL RECORD
(Form to be completed by employee)
NAME OF FACILITY
FACILITY ADDRESS
FACILITY FILE NUMBER
1.
PERSONAL
TELEPHONE
NAME (LAST
FIRST
MIDDLE)
(
)
ADDRESS
ARE YOU 18 YEARS OF AGE OR OLDER?
YES
NO
IF NO, PLEASE STATE YOUR AGE
_____________________________
SOCIAL SECURITY NUMBER: (VOLUNTARY FOR ID ONLY)
DATE OF LAST PHYSICAL EXAMINATION
DATE OF LAST TB TEST
-
-
HAVE YOU EVER BEEN EMPLOYED UNDER A DIFFERENT NAME?
YES
NO
IF YES, PLEASE LIST ALL NAMES USED.
DO YOU POSSESS A VALID CALIFORNIA DRIVER'S LICENSE?
YES
NO
HAS YOUR DRIVER'S LICENSE EVER BEEN SUSPENDED OR REVOKED?
YES
NO
CDL NUMBER
IF YES, PLEASE EXPLAIN ON BACK OF FORM.
NEAREST LIVING RELATIVE — NAME:
TELEPHONE NUMBER
RELATIONSHIP
ADDRESS
2.
POSITION
TITLE
SALARY
HOURS
DATE OF EMPLOYMENT
NAME OF SUPERVISOR
3.
PREVIOUS EMPLOYMENT
(List most recent experience first. If additional space is needed, please attach a separate page.)
TELEPHONE
JOB TITLE AND
DATES
REASON FOR
NAME AND ADDRESS OF EMPLOYER
NUMBER
TYPE OF WORK
FROM
TO
LEAVING
4.
EDUCATION
CIRCLE HIGHEST YEAR COMPLETED
DIPLOMA
CURRENTLY ENROLLED IN HIGH SCHOOL COMPLETION COURSE?
6
7
8
9
10
11
12
NO
YES IF YES, GIVE EXPECTED COMPLETION DATE___________________
EMPLOYMENT — RELATED EDUCATION COURSES
NUMBER
NAME OF SCHOOL OR ORGANIZATION
CURRENTLY
DATE
UNITS
COURSE TITLE
AND ADDRESS
ENROLLED
COMPLETED
COMPLETED
LIC 501 (3/99)
(OVER)
4.
EDUCATION (Continued)
NO. OF
NO. OF
DIPLOMA
NAME UNIVERSITY, COLLEGE OR BUSINESS SCHOOL
MAJOR
YEARS
UNITS
DEGREE OR
DATE
AND ADDRESS
SUBJECT
COMPLETED
COMPLETED
CERTIFICATE COMPLETED
5.
REFERENCES
List names of three persons who can give information about your background, character, abilities, etc.
TELEPHONE
RELATIONSHIP TO YOU
NAME
ADDRESS
NUMBER
(FRIEND, EMPLOYER, ETC.)
6.
PROFESSIONAL AND TECHNICAL QUALIFICATIONS
A. List Licenses or Certificates of Competence held:
B. Names of Professional Associations of which you are a member:
NOTES:
I hereby certify under penalty of perjury that the above statements are true and correct. I give my permission for any necessary verification.
SIGNATURE OF EMPLOYEE
DATE
ADVERTISEMENT
Fill PDF online
Page of 2