Employment Application Form - Contra Costa Humane Society - California

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Employment Application
1. Position Applied For:
2.
Agency
2. Social Security No.:
3. Full legal Name:
Last Name
First
Middle
(
)
4. Home Phone:
(
)
Cell Phone
5. Street Address:
Zip
City
State
6. E-mail Address:
7. Education:
7a. Highest school grade completed:
1
2
3
4
5
6
7
8
9
10
11
12
7b. Do you have a high school equivalency diploma:
Yes
No
7c. Number of years of post high school education:
1
2
3
4
8. Education Information
8a
8b
8c
Name of Educational
Institution
Major/Specialty
Dates Attended
Degree Received
9. If you plan to complete an educational program in the future, indicate the degree or program to be completed and completion date:
10. Work Experience: Start with the most recent work experience. Describe your knowledge, skills and abilities that demonstrate your
qualifications for the position for which you are applying.
10a
10b
Job Title
Employer Name
Employer Address
Phone Number
Supervisor
Final Salary
Dates of Employment
Job Duties
Reason for Leaving
11. Job Skills: Use the following space to provide any additional information that you think would be helpful in our evaluation of your job
application. This can include specialized training, seminars, workshops, accreditations, special achievements or valuable skills:
12. Licenses Held: (including drivers) or certifications to practice a trade or profession.
Type
License Number
Granted by (licensing board)
Employment Application
1. Position Applied For:
2.
Agency
2. Social Security No.:
3. Full legal Name:
Last Name
First
Middle
(
)
4. Home Phone:
(
)
Cell Phone
5. Street Address:
Zip
City
State
6. E-mail Address:
7. Education:
7a. Highest school grade completed:
1
2
3
4
5
6
7
8
9
10
11
12
7b. Do you have a high school equivalency diploma:
Yes
No
7c. Number of years of post high school education:
1
2
3
4
8. Education Information
8a
8b
8c
Name of Educational
Institution
Major/Specialty
Dates Attended
Degree Received
9. If you plan to complete an educational program in the future, indicate the degree or program to be completed and completion date:
10. Work Experience: Start with the most recent work experience. Describe your knowledge, skills and abilities that demonstrate your
qualifications for the position for which you are applying.
10a
10b
Job Title
Employer Name
Employer Address
Phone Number
Supervisor
Final Salary
Dates of Employment
Job Duties
Reason for Leaving
11. Job Skills: Use the following space to provide any additional information that you think would be helpful in our evaluation of your job
application. This can include specialized training, seminars, workshops, accreditations, special achievements or valuable skills:
12. Licenses Held: (including drivers) or certifications to practice a trade or profession.
Type
License Number
Granted by (licensing board)
13. References:
List the full name, address, phone number and relationships of up to three persons that you’d like to use as references:
Full Name
Address
Phone Number
Relationship
14. Scheduling:
14a. Are you able to work weekends and evenings as needed:
Yes
No
14c. Are you willing to travel up to 30 miles for the job duties:
Yes
No
15. Are you in compliance with the Immigration Reform and Control Act requires that you are you legally eligible for employment in the United
States?
Yes
No
Please note that under the Immigration Reform and Control Act of 1986, that you may be required to fill out a certification verifying that you are
eligible to be employed and verifying your identity. You may also be will be required to provide documentation that you should you be employed.
16. Prior Convictions:
16a. Have you ever been convicted of any violation of law, including moving traffic violations:
Yes
No
If yes, then please provide the following:
Describe the Offense :
Statute / Ordinance (if known):
Date of Charge:
Date of Conviction:
County, City, State of Conviction:
17. Work Start Date: When will you be available to start work?
Month
Day
Year
18. Job Application Certification:
Day
I hereby certify that all entries on this job application and any attachments are true and complete. I also agree and understand that any
Year
falsification this information may result in my forfeiture of employment.
I understand that all information on this job application is subject to verification and I consent to criminal history and background checks. I also
agree that you may contact references and educational institutions listed on this application
Dated
Job Applicant Signature
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