CALIFORNIASTATEUNIVERSITYSACRAMENTOUNIVERSITY POLICE

6000 J Street

SacramentoCA 95819-6092

CommunityServiceOfficerProgramApplicationforEmployment

PositionTitle:Date:

Name:

(Last)(First)(MI)

Address:

(NumberStreet)(City)(State)(Zip)

Telephone:SaclinkEmailAddress:

(Home)(Cell)

Where did you learnabout thisPosition?

Newspaper:Sacramento StateWebSite:_ Job Line: Other:

1.Are you currently a Sacramento State Student? Yes:No:

2.Youmustbeatleast18years ofage or,ifunder18,you musthavegraduated fromhigh school orhaveacertificate ofproficiency in order to be employed by the University. Do you meetthisrequirement?

Yes:No:

3.Are you currentlyauthorizedto work in the UnitedStates? Yes:No:(ProofofCitizenship or Immigration status isrequireduponemployment). Ifyou are not currentlyauthorized towork inthe U.S.,please state your immigrationstatus.

4.Haveyou ever beenreleased or dischargedfromemployment or resignedtoavoid suchrelease ordischarge? Yes: No: IfYes,please explain:

Date ofdischarge or resignation:

Reason for discharge or resignation:

5.Sinceyour18thbirthday, haveyou ever beenconvicted ofa felony? Yes:No: Ifyou answeredYes,list the circumstances, placeand dates:(A convictionwill not necessarilydisqualifyyou fromemployment. Wewill consider your case individually, inrelationtothe position forwhichyouhave applied.

6.Educationandtraining(includemilitarytraining).Circle the highest grade completed:Grammar: 1 2 3 4 5 6 78 High:9 10 11 12 College: 13 14 15 16 Grad:17 18 19 20

Education/TrainingFacility / SubjectsStudied(list all major
minor) / UnitsTaken / DegreesReceived(AA,BA,MS,PhD,etc.

7.Professional/TechnicalLicense/Certificates:

TypeofLicense/Certificate / License/Certificate # / State/OrganizationIssued By / ExpirationDate

8.Please provide the following information and indicate the skillsyou possess only iftheyare arequirement ofthe positionfor whichyouareapplying:

Driver’sLicense #:State:Class:Software Proficiency:

Languages you speak,read or write fluently inadditiontoEnglish:

EmploymentRecord: Listyour present ormost recentemployer first.Describe your employment history,accountingfor alltimeduringat least the pastfive (5) years.Youmayinclude volunteer and paid experience,do notsubstitutea resume. Youmayattach additional informationsuch as a resume and letterofrecommendation.

Do you wishto be notifiedbefore we contact your current employer:Yes:No:

Do you wishto be notifiedbefore we contact your previousemployer:Yes:

No:

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Employer:Address: Immediate Supervisor Title: Telephone: Your Job Title: DatesEmployedFrom: To: Job Duties: (briefstatement; besure to listalldutiesrelatedtothisposition)

StartingSalary $:Ending Salary $:HoursPer Week: Reason for Leaving:

Employer:Address: Immediate Supervisor Title: Telephone: Your Job Title: DatesEmployedFrom: To: Job Duties: (briefstatement; besure to listalldutiesrelatedtothisposition)

StartingSalary $:Ending Salary $:HoursPer Week: Reason for Leaving:

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Employer:Address: Immediate Supervisor Title: Telephone: Your Job Title: DatesEmployedFrom: To: Job Duties: (briefstatement; besure to listalldutiesrelatedtothisposition)

StartingSalary $:Ending Salary $:HoursPer Week: Reason for Leaving:

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Employer:Address: Immediate Supervisor Title: Telephone: Your Job Title: DatesEmployedFrom: To: Job Duties: (briefstatement; be sure to listalldutiesrelatedtothisposition)

StartingSalary $:Ending Salary $:HoursPer Week: Reason for Leaving:

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Employer:Address: Immediate Supervisor Title: Telephone: Your Job Title: DatesEmployedFrom: To: Job Duties: (briefstatement; besure to listalldutiesrelatedtothisposition)

StartingSalary $:Ending Salary $:HoursPer Week: Reason for Leaving:

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For additionalemployment history, please attach on a plain sheet ofpaper in the sameformat.

Brieflydescribe howyour experience,education,aptitudes, and interest relate tothisposition:

I,,wishtobeconsideredforemploymentwiththeSacramentoStatePoliceDepartment.Icertifythatallthestatementsmadeonthisapplicationaretrue,complete,andcorrecttothebestofmyknowledgeandbelief,andaremadeingoodfaith.IherebyauthorizetheSacramentoStatePoliceDepartmentanditsagentstoinvestigateandverifyallstatementsobtainedinmyemploymentapplicationandtoobtaininformationconcerningmyqualificationsasaprospectiveemployee.Iunderstandthatjob-relatedbackgroundchecksarerequiredforcertainpositions, the check will beconductedandcompletedbeforeappointmentorpromotiontothatposition. Iunderstandthatfailuretoprovide mandatoryinformation and/orfalsificationmaybe grounds for disqualification or separation.

Inconnectionwiththeinvestigationofthisapplication,IauthorizetheSacramentoStatePoliceDepartmenttocontacteachofmyformeremployers,educationalinstitutionsandreferenceslistedherein.Ialsoauthorizeeachoftheformeremployers,educationalinstitutionsandthereferenceslistedhereintogivetheSacramentoStatePoliceDepartmentanyandallinformationconcerningmyeducation,previousemployment,andanypertinentinformationtheymayhaveregardingmyworkperformance,whethersuchinformationisfavorableorunfavorabletome.IherebyfullyreleaseallsuchpersonsandentitiesfromanyliabilitywithrespecttofurnishingsuchinformationtotheSacramentoStatePoliceDepartment,andwaiveanyclaimsImayhaveagainstthemwithrespecttoreleaseofsuch information. IalsoauthorizeSacramentoStatePoliceDepartmenttoreleasesuchemploymentinformationasnecessarytothoseemployeesandagentsoftheSacramentoStatePoliceDepartmentwhorequiresuchinformationtoinvestigateortomakeadecisionwithrespecttoanymatter ofmyemployment.

AllinformationprovidedmaybeusedonlyforthepurposeofemploymentinaccordancewiththeCalifornia InformationPractices Actof1977.

Signature:Date: