Name (required)
Street Address: (required)
City: (required)
State: (required)
Zip Code: (required)
Telephone: (required)
Email: (required)
Position Applied For: (required)
Desired Salary: (required)
Date Available to Start Work: (required)
If applying for temporary work, during what period of time will you be available?
If yes, specify dates:
If yes, please specify the name under which you were employed or enrolled:
If necessary, please indicate what type(s) of reasonable accommodations are needed:
Please list any job-related professional, trade, business or civic activities, organizations and associations to which you belong. (You may omit those which indicate race, color, religion, national origin, ancestry, sex, age, or the existence of a disability.): (required)
If yes, which language(s)?
If yes, state name(s) and relationship(s)
What prompted you to apply for employment with the Camarillo Health Care District? (required)
Referral:
Type of license/certification:
Issuing state/Agency:
License/certification number:
If yes, state reason(s), date of revocation or suspension and date of reinstatement:
Please list your educational history, both high school and college, including the name of the school, years completed, graduation status, and any degrees you possess: (required)
Do you have any other experience, training, qualifications or skills which you feel make you especially suited for work at the Camarillo Health Care District? If so, please explain:
Please list your computer hardware/software skills: (required)
Please list your present and past work experience for the last 10 years, beginning with your current job. You may include volunteer activities. If you need additional space, please use the text box below the questions, following the same format. You must complete this section even if attaching a resume. Name of employer: (required)
From: (Month, Year) (required)
To: (Month, Year) (required)
Address: (required)
Phone: (required)
Position: (required)
Supervisor: (required)
Description of Duties: (required)
Reason for Leaving: (required)
Please use this space to cover any other previous employment, following the structure of the questions above.
If yes, please state branch of service:
Have you obtained any special skills or abilities as the result of service in the military?
List three persons who have knowledge of your work performance. Please do not include relatives. Name: (required)
Number of Years Acquainted: (required)
Address:
Telephone Number: (required)
Position/Capacity in Which Known: (required)
Name: (required)
Number of Years Acquainted: (required)
Address: (required)
Telephone Number: (required)
Position/Capacity in Which Known: (required)
Name: (required)
Number of Years Acquainted: (required)
Address: (required)
Telephone Number: (required)
Position/Capacity in Which Known: (required)
I hereby certify that the information contained in this application is true and correct to the best of my knowledge. I agree to have any of the statements checked by the Camarillo Health Care District (hereinafter referred to as the CHCD) unless I have indicated to the contrary. I authorize the references listed above, as well as all other individuals whom the CHCD contacts, to provide the CHCD any and all information concerning my previous employment and any other pertinent information that they may have. Further, I release all parties and persons from any and all liability for any damages that may result from furnishing such information to the CHCD as well as from the use or disclosure of such information by the CHCD or any of its agents, employees, or representatives. I understand that any misrepresentation, falsification, or material omission of information on this application may result in my failure to receive an offer or, if I am hired, my dismissal from employment. In consideration of my employment, I agree to conform to the rules and standards of the CHCD. I further agree that my employment and compensation can be terminated at-will, with or without cause, and with or without notice, at any time, either at my option or the option of the CHCD. I understand that no employee or representative of the CHCD, other than the Chief Executive Officer (CEO), has the authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing. Further, the CEO may not alter the at-will nature of the employment relationship unless the CEO and I both sign a written agreement that clearly and expressly specifies the intent to do so. I agree that this constitutes an integrated agreement with respect to the at-will nature of my employment relationship, that it is final and fully binding, and that there are no oral or collateral agreements regarding this issue. I also understand that all offers of employment are conditioned on the provision of satisfactory proof of an applicant’s identity and legal authority to work in the United States. By typing my name in the box provided, I understand I am providing a legal proxy for my signature. (required)
Date:
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