Form LIC501 "Personnel Record" - California

What Is LIC 501 Form?

Form LIC 501, Personnel Record, is a legal document completed by every community care employee to provide an employer with information concerning the employee's personal details and employment experience. It serves as an employment application and is kept in an employee personnel file to be later used to assess the employee's qualifications for employment, transfer, promotion, compensation, and disciplinary action.

This form was released by the California Department of Social Services (CDSS), a component of the California Health and Human Services Agency (CHHS). The latest version of the form was issued in March 1999 with all previous editions obsolete.

You can download a fillable LIC 501 Form through the link below. If you prefer to complete a Spanish version of the document, download Form LIC 501 (SP), Historial de Empleo/Educacion on our website using this link.

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Form LIC 501 Instructions

A Personnel Record (LIC 501) Form is filled out if an administrator is not the licensee. Otherwise, the same information is gathered on Form LIC 215, Applicant Information, which allows any individual to obtain a facility license.

Provide the following information on the LIC 501 Form:

  1. Personal information - full name, address, telephone number, age, social security number, dates of the last physical examination and tuberculosis test, other names you have been employed under, driver's license number and information. You are also required to provide details of your nearest living relative;
  2. Position - state the title, salary, hours, date of employment, and the name of your supervisor;
  3. Previous employment - list the employer's name, address, and telephone number. Indicate your job title, type of work, the reason for living, and dates of employment;
  4. Education - enter the course title, name of the school, and dates of enrollment;
  5. References - name three individuals who can give information about your background, abilities, and character;
  6. Professional and technical qualification - list the licenses and certificates you hold and write down the names of professional associations of which you are a member.
  7. Your signature and the actual date.
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Download Form LIC501 "Personnel Record" - California

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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
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