CHARIS YOUTH CENTER 714 W. Main St · Grass Valley, CA 95945 (530) 477-9800 · Fax (530) 477-9803

Employment Application

Personal Information
Last Name
First Name
Middle Name
Street Address
City
State
Zip Code
Phone
Other names you have had
Position Desired
Job Title
Desired Salary
Date Available
Type of Employment			Full-Time On Call	Part-Time Internship
Have you ever applied before?			Yes	No
If yes, give date
What prompted your application to our company?			Advertisment Agency	Referral Other
Personal History
Date of First Aid Card
Date of Last Physical Exam
Date of Last TB
Education and Training
High School
Did you graduate from High School?			Yes	No
If no, did you receive a GED or equivalent?			Yes	No
College / University
	Name
	Location
Diploma, degree or certificate obtained?			Yes	No
	List degree(s) received
If a degree was not obtained, list the number of credits completed
List other job-related training, scholastic honors, professional licenses, certifications or credentials. Official documentation may be required if hired.
Experience
Most Recent Employer
	Company
	Company (cont.)
	Address
	Address (cont.)
	Supervisor's Name
	Phone Number
	May we Contact?		Yes	No
	Your Job Title
	Date Employed From
	Date Employed To
	Reason for Leaving
Previous Employer
	Company
	Company (cont.)
	Address
	Address (cont.)
	Supervisor's Name
	Phone Number
	May we Contact?		Yes	No
	Your Job Title
	Date Employed From
	Date Employed To
	Reason for Leaving
Previous Employer
	Company
	Company (cont.)
	Address
	Address (cont.)
	Supervisor's Name
	Phone Number
	May we Contact?		Yes	No
	Your Job Title
	Date Employed From
	Date Employed To
	Reason for Leaving
References
Reference 1
Name
Phone Number
Relationship
Reference 2
Name
Phone Number
Relationship
Reference 3
Name
Phone Number
Relationship
Other
Do you meet the minimum age requirement of 21 years of age?			Yes	No
Can you submit verification of your identity and legal right to work in the United States?			Yes	No
It is a requirement for employment in a Community Care Licensing Facility that fingerprinting is conducted and reviewed for employment approval by the California Department of Social Services, Community Care Licensing Divisions' Caregiver Background Check Bureau (CBCB). I have read the statement on fingerprint requirements to work at Charis youth center.			Yes	No
Do you meet the requirements to have a current, valid California driver's license?			Yes	No
I understand that as part of the condition for employment that my driving record will be reviewed and must meet the agency's insurance company's requirements to be a covered driver.			Yes	No
Employee Availability
	Employees hired to work in the School, Rehabilitative Enrichment Program, or Residential Program may be scheduled to work within the following time frames:
Teacher Counselors School Days 2:00 pm - 10:00 pm Non-School Days 7:30 am - 10:00 pm Weekends 7:30 am - 3:00 pm 3:00 pm - 10:00 pm or double shifts Teaching Assistants School Days 6:30 am - 3:00 pm Non-School Days 7:30 am - 3:30 pm Weekends NA     Late Night Child Care Workers 10:00 pm - 7:30 am
I understand that availability to work assigned schedules is an important consideration for Charis Youth Center during the hiring process and therefore, I now state that, if hired, I am available to work as follows:
			From	To
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
	I certify that all statements are true, and I give permission for necessary verification.