Certification/License X Those That Apply

/ Compassionate Community Care
In-Home Assistance Program
1426 Fillmore Street, Suite 210
San Francisco, CA 94115
Phone: (415) 921-5038 Fax: (415) 921-5037
EMPLOYMENT APPLICATION
An Equal Opportunity, Reasonable Accommodation Employer
Name: / Social Security Number: / Date:
Address: / Home Telephone: / Other Number:
City: / State: / Zip Code:
Position Applied For:

EDUCATION RECORD

School Name / Location / DATES ATTENDED / DIPLOMA, DEGREE OR
CERTIFICATE EARNED / MAJOR FIELD
OF STUDY
High School
1.
2.
Colleges/Universities
1. / (Semester)
2.
Business/Technical/Vocational
1. / (Semester)
2.

LICENSES (Optional, unless required for the position for which you are applying.)

Certification/License – “X” those that apply

/ For positions, which require specific licenses, copies of licenses will be required at the time of interview.
Administrator: C M
Nursing: RN LVN CNA CHHA CMA
Expiration Date? ______Number: ______/ List other current licenses, certifications, or registrations required for the position for which you are applying. Indicate types and dates received.

SPECIAL SKILLS/LANGUAGES (Optional, unless required for the position for which you are now applying.)

List any special skills you possess and/or equipment or office machines you can operate.
Typing Test Score: WPM Tested by Job Service? Test Date:
Languages (Other than English):
1. Speak Read Write / 2. Speak Read Write

EMPLOYMENT HISTORY

Please list all employment or volunteer experience. Begin with your present or last position and work back. Provide sufficient, qualifying experience.

You may attach a resume reflecting your employment history in lieu of completing this portion of the application.

Employer: / Full-time
(+32 hrs/wk) / Position Title:
Address: / Part-time
(-32 hrs/wk) / Ending Salary:
City/State:
Start Date / End Date / Months in this position
Supervisor’s Name: / Supervisor’s Phone:
Reason for Leaving:
Describe responsibilities and duties you performed or skills you have that are required for the position for which you are applying.
Employer: / Full-time
(+32 hrs/wk) / Position Title:
Address: / Part-time
(-32 hrs/wk) / Ending Salary:
City/State:
Start Date / End Date / Months in this position
Supervisor’s Name: / Supervisor’s Phone:
Reason for Leaving:
Describe responsibilities and duties you performed or skills you have that are required for the position for which you are applying.
Employer: / Full-time
(+32 hrs/wk) / Position Title:
Address: / Part-time
(-32 hrs/wk) / Ending Salary:
City/State:
Start Date / End Date / Months in this position
Supervisor’s Name: / Supervisor’s Phone:
Reason for Leaving:
Describe responsibilities and duties you performed or skills you have that are required for the position for which you are applying.

SPECIAL QUALIFICATIONS:______

______

DISCLOSURE / AUTHORIZATION

Additional Information

May we contact your present employer? Yes NoMay we contact your former employers? Yes No

Have you ever been convicted of a crime or have you pled no contest within the last ten years? Yes No

If yes, list all such offenses and state date, name of court and disposition. You may omit minor violations for which you paid a fine of $50 or less.

Disclosure

Please be advised that as part of Compassionate Community Care’s employment process, the Company may obtain investigation reports about you in connection with your application for employment.

Investigation reports may include, but are not limited to, verification of education, past employment, criminal background reports, drug testing, finger prints, motor vehicle driving records, reference checks, civil suit records, and/or investigations into theft, fraud, abuse, drugs, harassment and workplace violence. This information may be obtained from personal interviews with your professional and personal acquaintances. You have the right to request in writing, within a reasonable period of time, a complete disclosure of the nature and scope of an investigation involving such personal interviews.

You should be aware that any information obtained pursuant to investigation is confidential. Any such information will be used solely for employment related considerations and not for any other purpose.

Drug Testing

During the employment application process, Compassionate Community Care reserves the right to test all potential employees.

Authorization

I have read and understand the above disclosure and hereby authorize Compassionate Community Care or its agent(s), to obtain any background investigation reports/drug testing on me in connection with my application for employment.

I understand that such investigation reports my include information about my professional experience, educational background, criminal record, character and general reputation.

I grant permission to any person or entity to release Compassionate Community Care or its agent(s) any and all information regarding my background. I waive any and all claims I may have with respect to providing such information.

I understand and agree that Compassionate Community Care and its agent(s) are not responsible for the accuracy or completeness of the information obtained in such reports. I release Compassionate Community Care and its agent(s) from all liability claims, and lawsuits with respect to the information obtained from any or all sources used by Compassionate Community Care and its agent(s).

I understand that this authorization is not an offer of employment by Compassionate Community Care and that any false or misleading information I have provided to Compassionate Community Care may result in a refusal to hire, promote, reassign, or continue employment.

I understand that this authorization is a continuing authorization and will remain valid until such time as I inform Compassionate Community Care, in writing, that I revoke this authorization.

I understand that if I am hired, it will be at the discretion of the Compassionate Community Care, and that any such employment is “at will” which means that Compassionate Community Care has no obligation to continue to employ me in the future.

I certify that I have made no misrepresentation in this application and I have not withheld information in my statements and answers to questions. I hereby authorize Compassionate Community Care to investigate and verity any representations made by me, either orally or in writing. I hereby release Compassionate Community Care, and any individual who provides or obtains information pursuant to this authorization, from any and all liability for damages of any kind, which may result to me on account of compliance, or attempts to comply, with this authorization. I understand that this application is the property of Compassionate Community Care and will become a part of my personnel file if I am hired.

Signature of Applicant: Date:

EEO Data

The following information is requested for record keeping purposes. The information will not be used for making employment decisions and will be separated from your application.

Personal Data

Job Title / Social Security No. / Last Name / First Name / Middle Initial
Address / City / State / Zip Code / Phone Number
Sex
M – Male F - Female / Date of Birth / Ethnic Origin
1-White 2- Black 3 – Hispanic 4 – Asian/Islander
5-Other
How did you find out about this job?
01 – CCC Web Page 05 – Local Newspaper
02 – Job Vacancy Bulletin 06 – Job Fair
03 – Employment Information Line 07 – Other
04 – Employee Referral
*If you selected 07 – Other, please specify source:

Signature: ______Date: ______

Compassionate Community Care services do not allow practices or policies that would enable discrimination against any person on the grounds of race, color, or national origin, or on the basis of disability or age with regard to its employment practices.