Cerritos College

Position Applying for:
[] Full-Time [] Part-time

11110 Alondra Blvd.

Norwalk, CA 90650-6298

(562) 860-2451

Classified Application for Employment

The District is strongly committed to achieving staff diversity and the principles of equal opportunity employment. The District encourages a diverse pool of applicants and does not discriminate on the basis of race, color, national origin, ancestry, sex, age, religion, marital status, disability, or sexual orientation in any of its policies, procedures or practices.

Last Name / First Name / Middle / Date:
Address / City / State / Zip / Home Telephone:
Email address: / Work Telephone:
Driver’s License Number (if required by position) / Expiration Date / State / Cell/Mobile Telephone:

EDUCATIONAL BACKGROUND: List High School and all accredited post-secondary educational institutions attended

High School Attended: / Graduated:
Yes No / GED:
Yes No
College and Universities
Name of Accredited Institution / State / Major / Dates of Attendance / Units Completed (semester or quarter units) / Degree (AA, BS, MA, etc) / Date Granted
From: / To:

OTHER CERTIFICATES OR LICENSES:

OFFICE/COMPUTER SKILLS: If applicable to position.

Present Typing/keyboarding speed (WPM) / List all computer software applications you have used

SPECIAL SKILLS:

List special skills and/or experience
Fluency in languages other than English. Indicate level of proficiency: Basic (B), Fluent (F)
Language / Read / Write / Speak / Language / Read / Write / Speak

EXPERIENCE:List most recent experience first. This section must be completed in full, additional sheets may be included if needed. You may attach a resume listing additional information.

Dates of Employment / Title / Employer Name
From:
To: / Major Duties / Supervisor Name
Full-time
Part-time / Supervisor Title
Hours per week: / Address
Seasonal / City, State, Zip
Salary (Hourly/Monthly) / Reason for Leaving / Area Code/Telephone
Dates of Employment / Title / Employer Name
From:
To: / Major Duties / Supervisor Name
Full-time
Part-time / Supervisor Title
Hours per week: / Address
Seasonal / City, State, Zip
Salary (Hourly/Monthly) / Reason for Leaving / Area Code/Telephone
Dates of Employment / Title / Employer Name
From:
To: / Major Duties / Supervisor Name
Full-time
Part-time / Supervisor Title
Hours per week: / Address
Seasonal / City, State, Zip
Salary (Hourly/Monthly) / Reason for Leaving / Area Code/Telephone
Dates of Employment / Title / Employer Name
From:
To: / Major Duties / Supervisor Name
Full-time
Part-time / Supervisor Title
Hours per week: / Address
Seasonal / City, State, Zip
Salary (Hourly/Monthly) / Reason for Leaving / Area Code/Telephone

MAY WE CONTACT YOUR CURRENT AND/OR PREVIOUS EMPLOYER(S) REGARDING YOUR QUALIFICATIONS AND/OR WORK PERFORMANCE? Current: Yes No Previous: Yes No

WORK REFERENCES: In addition to current or former supervisors, you may list additional work references. Do not include relatives.

Name / Title / Phone
Employer Name / Address, City, State and Zip Code
Name / Title / Phone
Employer Name / Address, City, State and Zip Code
Name / Title / Phone
Employer Name / Address, City, State and Zip Code

GENERAL INFORMATION:

Have you ever been employed by Cerritos College? / Yes No / If yes, when?
Do you have the legal right to work in the United States? / Yes No / If not, explain
Have you ever been discharged or forced to resign from any position? Yes No
Discharge from employment will not automatically disqualify you from employment, but failure to list all discharges may result in disqualification or dismissal. If your answer is yes, you must complete attached DISCHARGE STATEMENT FORM.
Have you ever been convicted of a criminal offense? Yes No
If yes, complete attached RECORD OF CONVICTION FORM.
You must answer YES if you were convicted, whether by plea, or jury verdict, or finding of guilt by a court in trial without a jury, irrespective of a subsequent order under Penal Code §1203.4 allowing the withdrawal of a plea of guilty and entering a plea of not guilty, or setting aside a verdict of guilt, or dismissing the accusations or information (you may omit minor traffic violations). A criminal record will not automatically disqualify you for employment, but failure to disclose a conviction record may result in disqualification or dismissal.
Do you have any relatives, by blood or law, who are currently employed by Cerritos College?
Name / Relationship / Title / Department

APPLICANT CERTIFICATION AND WAIVER:

I certify that the information I have provided in applying for this job is true and complete to the best of my knowledge and belief. I give Cerritos College and its authorized agents permission to verify and/or disclose any information given in connection with this application for personnel/employment purposes. I acknowledge that any misstatement or omission in the application materials may be cause for elimination from further consideration or dismissal if hired. I hereby authorize any and all persons and agencies to furnish to Cerritos College any information, including documents in my personnel file, which may be necessary to verify this application and any other materials submitted, and hereby waive any rights of privacy to the information or documents which I may have under any federal, state, or local law, ordinance or rule. I also understand that an incomplete application packet may delay or prevent employment opportunities with Cerritos College.

Applicant’s Signature:______Date: ______

Cerritos College is an Equal Opportunity Employer with a commitment to provide equal opportunity for all without regard to race, religion, national origin, sex, age, handicap, medical condition or Vietnam era veteran status. Cerritos College complies with Title IX Educational Amendment of 1962 prohibiting sex discrimination in education. If you have a disability, and require accommodation to complete this application, contact the Human Resources office.Cerritos College employs only individuals lawfully authorized to work in the United States. Cerritos College does not provide sponsorship for changes in immigration status for the purpose of employment in the United States.

HR011910-CL, Rvsd 010511

Cer Cerritos College

11110 Alondra Blvd.

Norwalk, CA 90650-6298

(562) 860-2451

Applicant Diversity Survey (Optional)

Supplemental Equal Employment Opportunity Application Information

Federal and State mandates require our institution to compile data on the sex, age, ethnicity, disability, and veteran status of applicants for employment opportunities. To assist us in complying with this requirement, we are requesting that you complete and return this form. This information will be used to evaluate the effectiveness of our recruitment efforts. It should be emphasized that it is the policy of the Cerritos Community College District to hire solely on the basis of the applicant’s qualifications in relation to the requirements and selection criteria for the particular position. Information obtained from the applicant on this survey is not provided to the selection committee responsible for making employment recommendations.

It should be understood that you have the option of providing or not providing the information requested, and that your decision in this matter will not affect the status of your application. Your cooperation in completing the survey is appreciated.

Last Name / First name / Middle
Position applied for:
GENDER: Male
Female / AGE: 40 years or over
Below 40 years / VIETNAM ERA VETERAN (August 4, 1964 - May 5, 1975)
No Yes

ETHNIC GROUP (with which you most closely identify):

American Indian or Alaskan Native / Asian or Pacific Islander
Japanese / Guamanian / Asian Indian
African American/Black / Chinese / Samoan / Filipino
Korean / Laotian / Hawaiian
Caucasian/White / Vietnamese / Cambodian / Asian Other
Pacific Islander Other
Hispanic/Latino
Mexican, Mexican-American, Chicano / Mixed Ethnic (Please specify the ethnic groups)
Central American
South American
Hispanic Other

DISABILITIES - Physical or mental impairment that limits one or more major life activities; has a record of such an impairment; or is regarded as having such an impairment.

None Yes, please identify:
How did you hear about this vacancy?

Applicant’s Signature: ______Date:

 PLEASE NOTE 
IF YOU ANSWERED YES TO THE QUESTION: Have you ever been convicted of a criminal offense? complete and submit this form with your application package, OTHERWISE, DO NOT SUBMIT IT.

Cerritos College

11110 Alondra Blvd.

Norwalk, CA 90650-6298

(562) 860-2451

Record of Conviction

Supplemental Employment Application Information

Submit with Application only if Necessary

Last Name / First Name / Middle / Position applied for:

Because of our responsibility to students and to the public, it is important to be extremely careful in screening applicants with conviction records. You may be disqualified from consideration for, or dismissed from employment with Cerritos College unless you fill out this form accurately and completely. In accordance with District policies, procedures, and the provisions of the Education Code, all prospective employees are fingerprinted and the fingerprints are submitted for verification.

In completing this form, you must include all sex offenses and controlled substance offenses even if they have been set aside by Penal Code section 1203.4, but you may omit minor traffic infractions. A criminal record will not automatically disqualify you from your employment, but failure to list all convictions may result in disqualification or dismissal.

INSTRUCTIONS: In the space below, give complete details for every time you have pled guilty, been convicted, fined, imprisoned, placed on probation, or given a suspended sentence in court. Please indicate if the situation was a misdemeanor or felony offense. If you are in doubt, list the conviction and explain. Do not include minor traffic infractions where the fine was $300 or less. For additional space, use a separate sheet.

Offense
(Brief Description) / Offense Code No.
(if known) / Date
Mo/Yr / Location
(City & State) / Disposition (imprisonment, fine, probation, suspended sentence) / Misd* / Flny*

* Misd = Misdemeanor Flny = Felony

Are you currently out on bail or released on your own recognizance pending trial regarding a criminal matter? / No Yes (please complete information below)

INSTRUCTIONS: In the space below, give complete details regarding the criminal matter(s) for which you are currently out on bail or released on your own recognizance. For additional space, use a separate sheet.

Offense
(Brief Description) / Offense Code No.
(if known) / Date
Mo/Yr / Location
(City & State) / Disposition (imprisonment, fine, probation, suspended sentence) / Misd* / Flny*

* Misd = Misdemeanor Flny = Felony

DECLARATION:I declare under penalty of perjury under the laws of the State of California that the information listed above is true and complete.

Applicant’s Signature: ______Date: ______

Cerritos College

 PLEASE NOTE 
IF YOU ANSWERED YES TO THE QUESTION: Have you ever been discharged or forced to resign from any position? complete and submit this form with your application package, OTHERWISE, DO NOT SUBMIT IT.

11110 Alondra Blvd.

Norwalk, CA 90650-6298

(562) 860-2451

Discharge Statement

Supplemental Employment Application Information

Submit with Application only if Necessary

Last Name / First Name / Middle
Position applied for:

INSTRUCTIONS: In the space below, give complete details for every time you were discharged or forced to resign from any position. Discharge from employment or forced resignation will not automatically disqualify you from employment, but failure to list all discharges or forced resignations may result in disqualification or dismissal from employment.

DECLARATION:

I declare under penalty of perjury under the laws of the State of California that the information listed above is true and complete.

Applicant’s Signature: ______Date: ______

1