Personnel Record Form

* Required Information

Date

Name of Facility

Facility Address

Facility File Number

Personal

Position Applying For

Name *

Address *

Telephone

Are you 18 years of age or older?

Yes

Social Security Number (Voluntary ID only)

Please state your age

Date of last physical examination

Date of last TB Test

Have you ever been employed under a different name?

Yes

Do you possess a valid California driver's license?

Yes

Please list all names used

CDL Number

Has your driver's license ever been suspended or revoked?

Yes

Please explain on back of form

Nearest Living Relative - Name

Address

Telephone Number

Relationship

Position

Title

Salary

Hours

Name of Supervisor

Date of Employment

Previous Employment (List most recent experience first. If additional space is needed, please attach a separate page.)

Name and Address of Employer

Telephone Number

Job Title and Type of work

Reason for Leaving

Dates

From

Name and Address of Employer

Telephone Number

Job Title and Type of work

Reason for Leaving

Dates

From

Name and Address of Employer

Telephone Number

Job Title and Type of work

Reason for Leaving

Dates

From

Attach Resume

Choose a file

Education

Currently enrolled in high School completion course?

Yes

Give expected completion date

Diploma

EMPLOYMENT - RELATED EDUCATION COURSES

Course Title

Name of school or organization and address

Number units completed

Date completed

Currently Enrolled

Name University, College or Business School and Address

Major Subject

No. of years completed

No. of Units Completed

Diploma degree or Certificate

No. of Units Completed

References

List names of three persons who can give information about your background, character, abilities, etc.

Name

Address

Telephone Number

Relationship to you

Name

Address

Telephone Number

Relationship to you

Name

Address

Telephone Number

Relationship to you

Professional and Technical Qualifications

List Licenses or Certificates of competence held

Names of Professional Associations of which your are a member

Notes

Upload resume

Upload Certifications

Upload Licenses

I hereby certify under penalty of perjury that the above statements are true and correct. I give my permission for any necessary verification.

Name of Employee *

Date *

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