1453 Morab Way

Norco, Ca. 92860

909-522-2621 or 909-534-1533

Professional Personnel Application

Note: Complete all blanks –do not write “see resume”or application will not be considered.

Please print or type

Date:

Last / First / Middle
Home Address / City/State / Zip
Telephone / Home / Cell

Interested in applying for: Check all that apply

Program Supervisor / Instructional Behavioral Interventionist / Specialist (specify) / Clerical

Educational Background:

Credentials and or certificates to be included with application: Resume, copy of transcripts showing experience

High school / City/State / Dates Attended / Graduation Year
College/University / City/State / Dates Attended / Major / Graduation Year
College/University / City/State / Dates Attended / Major / Graduation Year
College/University / City/State / Dates Attended / Major / Graduation Year

Employment Experience:

Job Title: / Employer: / Current employer:
Starting Date: / End Date: / Supervisor & Number
City/State / Salary Type (wk,bi-week, monthly) / Starting Base Salary($)
Ending Base Salary($)
Duties Performed:
Reason for leaving:
Can we contact employer for a reference check:
Job Title: / Employer: / Current employer:
Starting Date: / End Date: / Supervisor & Number
City/State / Salary Type (wk,bi-week, monthly) / Starting Base Salary($)
Ending Base Salary($)
Duties Performed:
Reason for leaving:
Can we contact current employer for a reference check:
Job Title: / Employer: / Current employer:
Starting Date: / End Date: / Supervisor & Number
City/State / Salary Type (wk,bi-week, monthly) / Starting Base Salary($)
Ending Base Salary($)
Duties Performed:
Reason for leaving:
Can we contact current employer for a reference check:

Licenses or certificates

Conference/Training / Date Attended

Other job-related skills

References: A minimum of three references are required. Give the full name and contact information for each reference. Please include only one personal reference and all others should be professional references. Please attach any and all reference letters to application

Name / Position / Phone

Please answer the following questions.

Can you furnish proof of citizenship or determination of intent?
Have you applied or been employed by Excel Ed. Services
Have you ever been terminated, nonrenewed, discharged, or suspended from past employment

Complete each question below: If you answer yes to any question, give a detailed explanation on a separate page and attach it to the application.

Have you ever been the subject of a criminal investigation or arrest that resulted in probation or a conviction?
Have you ever pleaded guilty or no contest in a court a law for any offense?

I hereby affirm that the information given by me in this application is true and complete to the best of my knowledge. I UNDERSTAND THAT ANY MISREPRESENTATION, FALSIFICATION, OR OMISSION WILL BE SUFFICIENT CAUSE FOR CANCELLATION OF THIS APPLICATION, OR DISCHARGE IF I HAVE BEEN EMPLOYED. Furthermore, it is understood that this application becomes the property of Excel Educational Services LLC, which reserves the right to accept or reject it.

I hereby apply for employment with Excel Educational Services LLC and give EES permission to make inquires or references and former employers concerning my general character and past performance. I understand that Excel Educational Services LLC will obtain or require me to obtain my criminal history from a law enforcement agency. I further agree that references and information that becomes apart of this record, may be revealed to all persons who participate in the selection of employees. In signing this application, I understand that all references and personal information become part of the application and are considered CONFIDENTIAL.

Applicant’s Signature:Date:

The information sought here will be carefully considered. The accuracy and completeness of the form is absolutely essential. Applicants are considered for all positions without regard to race, color, gender, religion, national origin, age, marital or veteran status, or the presence of a handicap or disability. The Age Discrimination in Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40 years of age. The Americans with Disability Act of 1990 prohibits discrimination against a qualified individual with a disability. Excel Educational Services LLC is an Equal Opportunity Employer.

For Office Use Only:

Interview Date:Hire Date:Director and/or Deputy Director Approval:

Revised 01022014 RV