(MACCC)
P.O. Box 3936
Merced, CA95344-1936 / application for
Employment
Personal Information
Name (Last, First, Middle): / Date:
Social Security Number: / Birth Date:
Home Address:
City: / State: / Zip:
Home Phone: / Business Phone:
Can you prove your U.S. Citizenship? Yes No
Are you willing to submit to fingerprinting and a background check? Yes No
Religious Affiliation:
Position You Are Applying For:
Board of Behavioral Sciences status & number (if any): / Physical Restrictions? / Yes No
Referred by: Date you can start: / How many hours per week?
Have you ever been arrested? Yes No
Education
High School (Name, City, State):
Graduation Yes No
College (Name, City, State):
Dates Attended: / Degree Earned:
College (Name, City, State):
Dates Attended: / Degree, Major:
Work History (give information about your last 3 jobs, starting with the most recent)
1-Employer / Dates Employed:
Address:
City: / State: / Zip:
Phone:
Title/Duties:
Supervisor's Name and Title:
Reason for Leaving:
2-Employer / Dates Employed:
Address:
City: / State: / Zip:
Phone:
Title/Duties:
Supervisor's Name and Title:
Reason for Leaving:
3-Employer / Dates Employed:
Address:
City: / State: / Zip:
Phone:
Title/Duties:
Supervisor's Name and Title:
Reason for Leaving:
References (The first reference should be your pastor or spiritual director)
1-Name:
Work Phone: Home Phone:
Address:
City: / State: / Zip:
Relationship to You: / Length of time:
2-Name:
Work Phone: Home Phone:
Address:
City: / State: / Zip:
Relationship to You: / Length of time:
3-Name:
Work Phone: Home Phone:
Address:
City: / State: / Zip:
Relationship to You: / Length of time:
please answer the following
(use additional pages if needed)
1)Briefly describe your spiritual journey from your first hearing of Christ.
2)Please explain your view of psychology and your perspective of how the integration of psychology and faith works.
3) What do you participate in for fun and entertainment?
4)How would you describe yourself to someone who was about to introduce you to a group?
I understand that the information is this application may be shared with supervisory leadership within MACCC as a means of communication in the decision to accept me as an employee of the MACCC. I hereby authorize this information to be shared with that leadership. I am aware that the information in this application will not be shared with anyone outside of MACCC leadership without written permission from me.
______
Applicant SignatureDate
MACCC Employment Application (revised 10/11/2016)