Personal Information |
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Last Name |
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First Name |
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Middle Name |
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Street Address |
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City |
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State |
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Zip Code |
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Phone |
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Other names you have had |
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Position Desired |
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Job Title |
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Desired Salary |
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Date Available |
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Type of Employment |
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Full-Time
On Call |
Part-Time
Internship |
Have you ever applied before? |
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Yes |
No |
If yes, give date |
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What prompted your
application to our company? |
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Advertisment
Agency
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Referral
Other |
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Personal
History |
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Date
of First Aid Card |
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Date
of Last Physical Exam |
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Date
of Last TB |
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Education
and Training |
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High School |
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Did you graduate from High School? |
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Yes
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No
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If no, did you receive a GED or equivalent? |
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Yes
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No
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College
/ University |
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Name |
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Location |
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Diploma, degree or certificate obtained? |
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Yes
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No
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List degree(s) received |
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If a degree was not obtained, list the number of credits completed |
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List other job-related training, scholastic honors, professional licenses, certifications or credentials. Official documentation may be required if hired.
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Experience |
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Most
Recent Employer |
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Company |
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Company (cont.) |
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Address |
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Address
(cont.) |
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Supervisor's
Name |
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Phone
Number |
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May
we Contact? |
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Yes |
No |
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Your
Job Title |
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Date
Employed From |
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Date
Employed To |
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Reason
for Leaving |
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Previous Employer |
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Company |
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Company (cont.) |
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Address |
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Address
(cont.) |
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Supervisor's
Name |
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Phone
Number |
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May
we Contact? |
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Yes |
No |
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Your
Job Title |
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Date
Employed From |
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Date
Employed To |
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Reason
for Leaving |
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Previous Employer |
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Company |
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Company (cont.) |
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Address |
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Address
(cont.) |
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Supervisor's
Name |
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Phone
Number |
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May
we Contact? |
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Yes |
No |
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Your
Job Title |
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Date
Employed From |
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Date
Employed To |
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Reason
for Leaving |
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References |
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Reference 1 |
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Name |
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Phone
Number |
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Relationship |
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Reference 2 |
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Name |
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Phone
Number |
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Relationship |
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Reference 3 |
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Name |
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Phone
Number |
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Relationship |
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Other |
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Do you meet the minimum age requirement of 21 years of age? |
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Yes |
No |
Can you submit verification of your identity and legal right to work in the United States? |
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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. |
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Yes |
No |
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Do you meet the requirements to have a current, valid California driver's license? |
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Yes |
No |
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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. |
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Yes |
No |
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Employee Availability |
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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
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School Days
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2:00 pm - 10:00 pm
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Non-School Days
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7:30 am - 10:00 pm
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Weekends
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7:30 am - 3:00 pm
3:00 pm - 10:00 pm
or double shifts
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Teaching Assistants
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School Days
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6:30 am - 3:00 pm
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Non-School Days
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7:30 am - 3:30 pm
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Weekends
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NA
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Late Night Child Care Workers
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10:00 pm - 7:30 am
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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: |
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From |
To |
Monday |
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Tuesday |
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Wednesday |
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Thursday |
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Friday |
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Saturday |
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Sunday |
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I certify that all statements are true, and I give
permission for
necessary verification. |
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