Employment Application | Careers (Casa Pacifica)

Applicant Information

Last Name*

First Name*

Middle Initial

Other Names Used

Social Security Number

Address Line 1*

Address Line 2

City*

State*

Zip Code*

Primary Phone*

Alternate Phone

E-mail Address*

Position Applying For*

Program/Location

Shelter/Residential - Lewis Road, Camarillo Community Based Services Other

If Community Based Services, what kind

TBS Wraparound CIRT SAFTY

Desired Salary*

Availability*

Days Days & Evenings Overnights Weekends

Employment Status Preference*

Regular Full Time Regular Part Time Per Diem / On-Call

Referred By (If newspaper or website, which one)

If hired, can you present evidence of your U.S. citizenship or proof of your legal right to live and work in this country?

US Citizen*

no yes

Have you ever been employed with Casa Pacifica before?*

no yes

If so, when?

To work with the population we serve we ask that you are at least 21 years old. Do you meet this minimum age?

At Least 21 Years Old*

no yes

Education Information

High School

City, State

From Date

To Date

Did You Graduate?

no yes

Diploma

College

Address

From Date

To Date

Did You Graduate?

no yes

Degree

Education - Other

Address

From Date

To Date

Did You Graduate?

no yes

Degree

Skills and License

Special Skills You May Possess

List any foreign languages in which you are fluent and are willing to assist in translation (optional)

Computer Programs Used

Medical/Professional License

Registration Number

State

Expiration Date

Previous Employment

Comany Name*

Phone*

Address*

Job Title*

Starting Salary*

Ending Salary*

Responsibilities*

Supervisor Name and Title*

Allow Casa Pacifica to contact this person?*

no yes

From Date*

To Date*

Reason for Leaving*

Company 2

Phone

Address

Job Title

Starting Salary

Ending Salary

Responsibilities

Supervisor Name and Title

Allow Casa Pacifica to contact this person?

no yes

From Date

To Date

Reason for Leaving

Company 3

Phone

Address

Job Title

Starting Salary

Ending Salary

Responsibilities

Supervisor Name and Title

Allow Casa Pacifica to contact this person?

no yes

From Date

To Date

Reason for Leaving

Additional Information

Do you have a valid CA Driver's License?*

no yes

If yes, please indicate Driver's License #

Have you ever had your driver’s license rejected or suspended within the last 3 years because of your driving record?

Driver's License Suspended

no yes

If yes, explain why:

Please list all the moving violations and accidents within the last 3 years.

Moving Violations

Title 22 of the Welfare and Institutions code requires that employees of Casa Pacifica submit their fingerprints through LIVE SCAN for the purpose of conducting a criminal record review. Do you agree to be fingerprinted?

Agree to Fingerprinting*

no yes

Have you ever been convicted of a misdemeanor or felony?

Convicted of Misdemeanor / Felony*

no yes

(note: this is not an automatic bar to employment) If yes, explain:

Explanation

Title 22 of the Welfare and Institutions code requires that all employees have a record of health exam including a TB test (or chest x-ray) upon employment and when otherwise required by the state. Does this pose a problem for you?

Health Exam Poses Problem*

no yes

As part of your application for employment with Casa Pacifica, a drug screen is required. Do you agree to take a drug screen?

Agree to Drug Test*

no yes

In compliance with the Americans with Disabilities Act, Casa Pacifica can and will employ people who have or have had disabilities. Are you able to perform the essential job requirements of the position for which you are applying?

Able to Perform Essential Tasks?*

no yes

Disclaimer*

I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in termination of my employment.

I authorize and hold harmless my former employers to release information pertaining to my work record and my work habits and performance while in their employ as well as the educational institutions I have attended as to my grades and educational performance.

I understand that Casa Pacifica reserves the right to require its employees to submit to physical and mental examinations, including blood tests or urinalysis for alcohol or drug screens and to inspect bags (including purses and briefcases) or parcels brought into or taken out of the work premises. I understand that refusal to submit to these types of exams or search when requested to do so may result in termination of my employment.

I understand and agree that if I am offered employment by Casa Pacifica my employment will be “at will” for no definite term and that either I or Casa Pacifica will have the right to terminate the employment relationship at any time, with or without cause, and with or without notice. I also understand that this status can only be altered by a written contract of employment that is specific as to all material terms and is signed by me and the chief executive officer.

I agree

Career

Application for Employment

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