A Not for Profit, 501C(3) Organization COMMUNITY CATALYSTS O F C A L I F O R N I A (Print Form) Print Form EmploymEnt ApplicAtion An EquAl opportunity EmployEr pAgE 1 Empowering Consumers, Enhancing Lives Be specific. If a question does not apply to you, write “NA” (not applicable.) If a question requires additional data, attach sheets as necessary. Be sure you have read the job description for the position for which you have applied prior to completing this application. Home Phone #: ______________________________ Message Phone: ___________________________ social security#: _____________________________ Date: ____________________________________ name (last, First Mi): ______________________________________________________________________ address: ________________________________________________________________________________ (TextField1) (TextField1) (TextField1) (TextField1) Permanent address if different from present address: ______________________________________________ Please Print (TextField1) (TextField1) (TextField1) (TextField1) EMPLOYMENT DESIRED: (TextField1) For which job/position are you applying?: ______________________________________________________ (CheckBox1) Unchecked regular full-time work (TextField1) (CheckBox1) Unchecked regular part-time work (CheckBox1) Unchecked temporary work (i.e. summer, internship) What days are you available for work? ________________________________________________________ (TextField1) What hours are you available for work? _______________________________________________________ (TextField1) if applying for temporary work, during what period of time will you be available? _________________________ are you available for work on weekends? (CheckBox1) Unchecked Yes (CheckBox1) Unchecked no Would you be available to work over time, if necessary? (TextField1) (CheckBox1) Unchecked Yes (CheckBox1) Unchecked no if hired, on what date can you start work? ______________________________________________________ PERSONAL INFORMATION: Have you ever applied to or worked for Community Catalysts of California before? (TextField1) (CheckBox1) Unchecked Yes (CheckBox1) Unchecked no If yes, when and which office? ___________________________________________________ Do you have friends or relatives working for Community Catalysts of California? (TextField1) (CheckBox1) Unchecked Yes (CheckBox1) Unchecked no if yes, state name(s) and relationship: _____________________________________________ (TextField1) Why are you applying for work at Community Catalysts of California? _________________________________ (TextField1) if hired, would you have a reliable means of transportation to and from work? Yes (CheckBox1) Unchecked (CheckBox1) Unchecked no (TextField2) rev. 1/10 A Not for Profit, 501C(3) Organization COMMUNITY CATALYSTS O F C A L I F O R N I A EmploymEnt ApplicAtion An EquAl opportunity EmployEr pAgE 2 Empowering Consumers, Enhancing Lives are you 18 years of age or older? (CheckBox1) Unchecked Yes (CheckBox1) Unchecked no (if under 18, hire is subject to verification that you are of minimum legal age) if hired, can you present proof of your legal right to work in the United states? (CheckBox1) Unchecked Yes (CheckBox1) Unchecked no are you able to perform the essential function of the job for which you are applying? (TextField1) (CheckBox1) Unchecked Yes (CheckBox1) Unchecked no if no, describe the functions that cannot be performed: ________________________________ (note: We comply with the aDa and consider reasonable accommodation measures that may be necessary for eligible applicant/ employees to perform essential functions.) Have you ever been convicted of a felony? (TextField1) (CheckBox1) Unchecked Yes (CheckBox1) Unchecked no if yes, state the nature of the crime(s), when and where convicted and disposition of the case: (note: no applicant will be denied employment solely on the grounds of conviction of a criminal offense. the nature of the offense, the date of the offense, the surrounding circumstances and the relevance of the offense to the position(s) applied for may, however, be considered.) are you currently employed? (CheckBox1) Unchecked Yes (CheckBox1) Unchecked no if yes, may we contact your current employer? (CheckBox1) Unchecked Yes (CheckBox1) Unchecked no EDUCATION, TRAINING AND EXPERIENCE Do you speak a language other than english? (CheckBox1) Unchecked Yes (TextField1) (CheckBox1) Unchecked no if yes, which language(s)? ______________________________________________________ Do you have prior experience with social service/health care? (TextField1) (CheckBox1) Unchecked Yes (CheckBox1) Unchecked no if yes, please explain: ________________________________________________________________ (TextField1) (TextField1) Do you have any other experience, training qualifications or skills that you feel make you especially suited for work at Community Catalysts of California? if so, please explain: ____________________________________ are you a high school graduate or equivalent? (CheckBox1) Unchecked Yes (CheckBox1) Unchecked no education: list all applicable educational experience, number of units, courses or degrees obtained. if you need additional space, continue on the back or on a separate sheet. SChOOL MAjOR OR COURSE CREDENTIALS CERTIFICATION/ DEGREE COLLEGE (TextField1) (TextField1) (TextField1) OThER (TextField1) (TextField1) (TextField1) OThER (TextField1) (TextField1) (TextField1) (TextField2) rev. 1/10 A Not for Profit, 501C(3) Organization COMMUNITY CATALYSTS OF CALIFORNIA Empowering Consumers, Enhancing Lives EMPLOYMENT hISTORY EmploymEnt ApplicAtion An EquAl opportunity EmployEr pAgE 3 List all present and past work experience starting with your most recent employer (Last 10 years is sufficient.) 1. Dates of employment: ______________ to ______________ name of employer: ______________________________ type of Business: ____________________ address: _____________________________________________________________________________ account for all time, including schooling, relevant military service and periods of unemployment. if you need additional space, continue on the back or on a separate sheet. You must complete this section even if attaching a resume. this is not considered to be your list of references. (TextField1) (TextField1) (TextField1) (TextField1) (TextField1) street City state Zip (TextField1) (TextField1) telephone #: ______________________________ supervisor/Contact name: __________________ (TextField1) (TextField1) (TextField1) Your Position: _____________________________ ending salary ___________________________ Your Duties: _______________________________________________________________________ (TextField1) 2. Dates of employment: ______________ to ______________ name of employer: ______________________________ type of Business: ____________________ address: _____________________________________________________________________________ reason for leaving: _________________________________________________________________ (TextField1) (TextField1) (TextField1) (TextField1) (TextField1) street City state Zip (TextField1) (TextField1) telephone #: ______________________________ supervisor/Contact name: __________________ (TextField1) (TextField1) (TextField1) Your Position: _____________________________ ending salary ___________________________ Your Duties: _______________________________________________________________________ (TextField1) 3. Dates of employment: ______________ to ______________ name of employer: ______________________________ type of Business: ____________________ address: _____________________________________________________________________________ reason for leaving: _________________________________________________________________ (TextField1) (TextField1) (TextField1) (TextField1) (TextField1) telephone #: Your Position: Your Duties: street City state Zip (TextField1) (TextField1) ______________________________ supervisor/Contact name: __________________ (TextField1) (TextField1) (TextField1) _____________________________ ending salary ___________________________ reason for leaving: _________________________________________________________________ (TextField2) rev. 1/10 (TextField1) A Not for Profit, 501C(3) Organization COMMUNITY CATALYSTS O F C A L I F O R N I A EmploymEnt ApplicAtion An EquAl opportunity EmployEr pAgE 4 4. Dates of employment: ______________ to ______________ name of employer: ______________________________ type of Business: ____________________ address: _____________________________________________________________________________ Empowering Consumers, Enhancing Lives (TextField1) (TextField1) (TextField1) (TextField1) (TextField1) telephone #: Your Position: Your Duties: street City state Zip (TextField1) (TextField1) (TextField1) (TextField1) (TextField1) ______________________________ supervisor/Contact name: __________________ _____________________________ ending salary ___________________________ reason for leaving: _________________________________________________________________ (TextField1) REFERENCES list contact information for references. a minimum of 3 must be provided, 2 of which must be professional. 3+ professional would be preferred. a maximum of 1 personal reference may be provided. name: _____________________________________ Company: __________________________________ (TextField1) telephone #: ________________________________ (TextField1) Reference #1 (TextField1) name: _____________________________________ Company: __________________________________ (TextField1) telephone #: ________________________________ (TextField1) Reference #2 (TextField1) name: _____________________________________ Company: __________________________________ (TextField1) telephone #: ________________________________ (TextField1) Reference #3 (TextField1) name: _____________________________________ Company: __________________________________ (TextField1) telephone #: ________________________________ (TextField1) Reference #4 (TextField1) relationship to you: _________________________ title: ____________________________________ (TextField1) (TextField1) Fax #: ___________________________________ (TextField1) (TextField1) relationship to you: _________________________ title: ____________________________________ (TextField1) Fax #: ___________________________________ (TextField1) (TextField1) relationship to you: _________________________ title: ____________________________________ (TextField1) Fax #: ___________________________________ (TextField1) (TextField1) relationship to you: _________________________ title: ____________________________________ (TextField1) Fax #: ___________________________________ (TextField1) (TextField2) rev. 1/10 A Not for Profit, 501C(3) Organization COMMUNITY CATALYSTS O F C A L I F O R N I A EmploymEnt ApplicAtion An EquAl opportunity EmployEr pAgE 5 Empowering Consumers, Enhancing Lives PLEASE READ CAREFULLY AND SIGN BELOw: I, hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of material fact on this application or on any document used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery. I, hereby authorize Community Catalysts of California to thoroughly investigate my references, work record, education and other matters related to my suitability for employment unless I have indicated to the contrary. I, further authorize my former employers to disclose to Community Catalysts of California any and all letters, reports and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release Community Catalysts of California, my former employers and all other persons, corporations, partnerships, and associations from any and all claims, demands, or liabilities arising out of or in any way related to such investigation or disclosure. In consideration of my employment, I agree to conform to the rules and standards of Community Catalysts of California and agree that my employment and compensation can be terminated at will, at the option of either Community Catalysts of California or myself with or without notice. I understand that no employee or representative of the company has the authority to enter into any agreement for employment for any specified period of time, or to make any express or implied agreement except in writing and approved by the Chief Executive Officer or the Board of Directors. Should I be employed by Community Catalysts of California, I agree that this shall constitute a fully binding agreement with respect to the at-will nature of my employment relationship. (CheckBox2) Unchecked I am waiving my right to receive written or verbal notification of information obtained by Community Catalysts of California through the reference and pre employment screening process associated to this employment application. __________(initial) applicant’s signature: _____________________________________ Date: _______________________ (TextField2) rev. 1/10