AEEmploymnt Appliction

EoAAn Equl pportunity Employr

EApg 1

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.

Please Print

ssocial ecurity#: 
(social security) 
Date: 
(Date) 


ilname (ast, First M): 
(name (last, First Mi) 


address: 
(address) 


aPermanent ddress if different from present address: 
(Permanent address if different from present address [2]) 
(Permanent address if different from present address [1]) 
________________________________________________________________________________________

Home Phone #: 
(Home Phone) 
Message Phone: 
(Message Phone) 


EMPLOYMENT DESIRED: 

For which job/position are you applying?: 
(For which job/position are you applying) 


 t rregular full-time workegular part-time work emporary work (i.e. summer, internship) 


What days are you available for work? 
(What days are you available for work) 


What hours are you available for work? 
(What hours are you available for work) 


if applying for temporary work, during what period of time will you be available? 
(if applying for temporary work, during what period of time will you be available) 


 n are you available for work on weekends?Yes o

n Would you be available to work over time, if necessary?Yes o

if hired, on what date can you start work? 
(if hired, on what date can you start work) 


PERSONAL INFORMATION: 

 n Have you ever applied to or worked for Community Catalysts of California before?Yeso

 Ifyes,whenandwhichoffice? 


 n Do you have friends or relatives working for Community Catalysts of California?Yeso

 if yes, state name(s) and relationship: 
(if yes, state name(s) and relationship) 


Why are you applying for work at Community Catalysts of California? 
(Why are you applying for work at Community Catalysts of California [2]) 
(Why are you applying for work at Community Catalysts of California [1]) 
________________________________________________________________________________________

 

 n if hired, would you have a reliable means of transportation to and from work?Yeso

 



AEEmploymnt Appliction

EoAAn Equl pportunity Employr

EApg 2

 n are you 18 years of age or older?Yeso

 (ifunder18,hireissubjecttoverificationthatyouareofminimumlegalage)

 n sif hired, can you present proof of your legal right to work in the United tates?Yeso

 n are you able to perform the essential function of the job for which you are applying?
(are you able to perform the essential function of the job for which you are applying) 
Yeso

 if no, describe the functions that cannot be performed: 


aan(ote: We comply with the D and consider reasonable accommodation measures that may be necessary for eligible applicant/
employees to perform essential functions.)

 n Have you ever been convicted of a felony?Yeso

 if yes, state the nature of the crime(s), when and where convicted and disposition of the case: 
(if yes, state the nature of the crime(s), when and where convicted and disposition of the case) 


 


tnn(ote: o applicant will be denied employment solely on the grounds of conviction of a criminal offense. he 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.)

 n are you currently employed?Yeso

 n if yes, may we contact your current employer?Yeso

EDUCATION, TRAINING AND EXPERIENCE

 n eDo you speak a language other than nglish?
(Do you speak a language other than english) 
Yeso

 if yes, which language(s)? 


 n Do you have prior experience with social service/health care?
(Do you have prior experience with social service/health care) 
Yeso

 if yes, please explain: 


 Doyouhaveanyotherexperience,trainingqualificationsorskillsthatyoufeelmakeyouespeciallysuitedforiwork at Community Catalysts of California? f so, please explain: 
________________________________________________________________________________________

 n are you a high school graduate or equivalent?Yeso

ileducation: ist all applicable educational experience, number of units, courses or degrees obtained. f you need 
additional space, continue on the back or on a separate sheet.

OOLCSh

OURSEORORAMj C

REDENTIALSC

ERTIFICATIONC/
EGREED

OLLEGEC

EROTh

EROTh





 



AEEmploymnt Appliction

EoAAn Equl pportunity Employr

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hEMPLOYMENT ISTORY

 Listallpresentandpastworkexperiencestartingwithyourmostrecentemployer(Last10yearsissufficient.)
iaccount for all time, including schooling, relevant military service and periods of unemployment. f you need 
additional space, continue on the back or on a separate sheet. You must complete this section even if attaching 
a resume.

e 1. Dates of mployment: 
(Dates of employment) 
to 
(to) 


tename of mployer: 
(name of employer) 
ype of Business: 
(type of Business) 


address:
(address) 
_____________________________________________________________________________

 s streetCitytateZip

ns t elephone #: 
(telephone) 
upervisor/Contact ame: 
(supervisor/Contact name) 


seYour Position: 
(Your Position) 
nding alary 
(ending salary) 


Your Duties: 
(Your Duties) 


lreason for eaving: 
(reason for leaving) 


e 2. Dates of mployment: 
(text) 
to 
(text) 


tename of mployer: 
(text) 
ype of Business: 
(text) 


address:
(text) 
_____________________________________________________________________________

 s streetCitytateZip

ns t elephone #: 
(text) 
upervisor/Contact ame: 
(text) 


seYour Position: 
(text) 
nding alary 
(text) 


Your Duties: 
(text) 


lreason for eaving: 
(text) 


e 3. Dates of mployment: 
(text) 
to 
(text) 


tename of mployer: 
(text) 
ype of Business: 
(text) 


address:
(text) 
_____________________________________________________________________________

 s streetCitytateZip

ns t elephone #: 
(text) 
upervisor/Contact ame: 
(text) 


seYour Position: 
(text) 
nding alary 
(text) 


Your Duties: 
(text) 


lreason for eaving: 
(text) 




AEEmploymnt Appliction

EoAAn Equl pportunity Employr

EApg 4

e 4. Dates of mployment: 
(text) 
to 
(text) 


tename of mployer: 
(text) 
ype of Business: 
(text) 


address:
(text) 
_____________________________________________________________________________

 s streetCitytateZip

ns t elephone #: 
(text) 
upervisor/Contact ame: 
(text) 


seYour Position: 
(text) 
nding alary 
(text) 


Your Duties: 
(text) 


lreason for eaving: 
(text) 


ELOIGNANDAREFULLYREADLEASEP C S Bw:

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

 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. 
(employment application) 
(initial)

sapplicant’s ignature: 
(signature) 
Date: 
(Date)