EMPLOYMENT APPLICATION
VICTOR COMMUNITY SUPPORT SERVICES, INC.
GRASS VALLEY, CA

Applied Previously to Agency Yes No Previously been employed by the Agency Yes No

Personal
Position Applied for:		Full Time Part Time
Last Name	First Name	Middle	AKA
Mailing Address	City	State	Zip Code
E-mail Address	Social Security Number	Home Phone	Message Phone
Have you ever been convicted of a Felony or Misdemeanor? Yes No
Date:	Description of conviction:
Are you a registered sex offender? Yes No
Are you 18 years or older? Yes No	How did you find out about our Agency?
Do you have a valid CA driver`s license? Yes No List any restrictions:
Languages (note fluency):
If you are offered employment, you will be required to produce sufficient documentation of your identity and right to work in the United States and to attest under penalty of perjury that the documents you have produced are genuine and relate to you. If hired, will you be able to provide proof of eligibility to work in the United States? Yes No
No offer of employment at the Agency is final until a prospective employee has passed the Agency's medical examination. The medical exam includes laboratory testing of a urine sample from a prospective employee to determine the presence of certain drugs and/or alcohol in the body. The post offer medical exam will also include an EDEX worker's compensation report to assist the clinic in determining ability to perform essential functions of the position. Do you agree to take a medical exam at the Agency's expense related to the essential requirements of the position? Yes No

Record of Education (Official/Sealed Transcripts required for Educational Credit)
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High School Name and Location		Highest Grade Completed	Did You Graduate?
		9 10 11 12	Yes No	Diploma GED
College Name and Location	Major	Total # of units completed	Year Graduated	Degree (i.e. AA, BA, Masters etc.)

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Skills, Licenses and Certificates:
Have you served in the military? Yes No

Professional References
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(Employers, Teachers, Internship, Volunteer work, Co-workers, Pastors)
Name	Occupation-Relationship	Email	Phone



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Do you have any relatives and/or friends employed with Victor?
Name:	Relationship:	Position with the Agency:
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List below all past and present employment, beginning with most recent, include all volunteer and paid experience (past ten years)

Employer	Date	Hourly Rate/Salary
Name	From To	Starting Final
Address	From To	Starting Final
City	State	ZIP
Position	Supervisor	Phone
Work Performed
Reason for Leaving
May we contact?	Yes No

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Please upload your resume to accompany your application.
The Agency`s policy is to fill every position without regard to race, color, religion, creed, sex, marital status, age, national origin, ancestry, physical handicap or any other consideration made unlawful by federal, state, or local laws. This Agency is an equal opportunity employer and selects employees on the basis of ability, experience, training, intelligence and character. Please contact the Executive Director if you have any questions or complaints regarding this policy. I, verify that the information I provided on this application is true and correct to best of my knowledge. I authorize the Agency to conduct an investigation into the accuracy of all my statements contained within this application, related papers, and orally during an interview process, as well as a thorough background check of my personal history by law enforcement agencies. I understand that falsification of data so given or other derogatory information discovered as a result of this investigation may prevent me from being hired, or, if hired, may subject me to immediate dismissal. I authorize the Agency to secure information concerning my experience, releasing all parties from any liabilities arising there from. If I am employed by the Agency, my employment status shall be that of an “at-will” employee; therefore, my employment may be terminated by me or by the Agency at any time. I further understand that such employment is for no definite period of time and the Agency can change wages, benefits, and conditions of my employment.