Employment Application

1. Personal

Name:

Telephone:

Email:

Address:

Are you 18 years of age or older?
 Yes No

If no, please state your age:

Have you ever been employed under another name?
 Yes No

If yes, list the name:

Do you possess a valid California Driver's License?
 Yes No

CDL Number:

Has your Driver's License ever been suspended or revoked?
 Yes No

If yes, please explain:

Nearest Living Relative - Name:
Telephone Number:
Relationship:

Address:

2. Position

Title:
Salary:
Hours:
Date of Employment:

Name of Supervisor:

3. Previous Employment

Name & Address of Employer:
Telephone Number:
Job Title & Type of Work:
Reason for Leaving:
Dates From:
To:

4. Education

Highest Year Completed:

Diploma:

Currently enrolled in high school completion course?
 Yes No
If yes, give expected completion date:

Employment - Related Education Courses
Course Title:

Name of school or organization address:
Number units completed:

Date completed:

Currently enrolled:

Name university, college, or
business school address:
Major subject:

No. of years completed:

No. of units completed:

Diploma degree or certificate:
Date completed:

5. References


List names of three persons who can give information about your background, character, abilities, etc.

Name
Address
Phone
Relationship

6. Professional and Technical Qualifications

A. List Licenses or Certifications of Competence held:

B. Names of Professional Associates of which you are a member:

Notes:

 I hereby certify under penalty that the above statements are true and correct. I give my permission for any necessary verification.

Signature:

Date: