Employment ApplicationName (required)Street Address: (required)City: (required)State: (required)Zip Code: (required)Telephone: (required)Email: (required)Position Applied For: (required)Desired Salary: (required)Date Available to Start Work: (required)Work Schedule: (required)Full TimePart TimeTemporaryIf applying for temporary work, during what period of time will you be available?If you are under age 18, can you provide a work permit if offered a job? (required)YesNoCan you, after employment, submit verification of your legal right to work in the U.S.? (required)YesNoHave you ever applied for a position or worked for the Camarillo Health Care District before? (required)YesNoIf yes, specify dates:To assist us in checking records and verifying prior employment and education, please indicate whether you were ever employed or enrolled under a name other than that used on this application:YesNoIf yes, please specify the name under which you were employed or enrolled:If you are employed now, may we contact your current employer?YesNoAre you able to perform the essential duties of the position for which you are applying, either with or without reasonable accommodations? (required)YesNoIf necessary, please indicate what type(s) of reasonable accommodations are needed:Please list any job-related professional, trade, business or civic activities, organizations and associations to which you belong. (You may omit those which indicate race, color, religion, national origin, ancestry, sex, age, or the existence of a disability.): (required)Some of our clients do not speak English. Do you speak, write, or understand any foreign languages? (required)YesNoIf yes, which language(s)?Do you have any friends or relatives working for the Camarillo Health Care District? (required)YesNoIf yes, state name(s) and relationship(s)What prompted you to apply for employment with the Camarillo Health Care District? (required)Referral:Do we have your permission to distribute your application to other agencies? (required)YesNoAre you licensed/certified for the job applied for? (required)YesNoType of license/certification:Issuing state/Agency:License/certification number:Has your license/certification ever been revoked or suspended?:YesNoIf yes, state reason(s), date of revocation or suspension and date of reinstatement:Please list your educational history, both high school and college, including the name of the school, years completed, graduation status, and any degrees you possess: (required)Do you have any other experience, training, qualifications or skills which you feel make you especially suited for work at the Camarillo Health Care District? If so, please explain:Please list your computer hardware/software skills: (required)Please list your present and past work experience for the last 10 years, beginning with your current job. You may include volunteer activities. If you need additional space, please use the text box below the questions, following the same format. You must complete this section even if attaching a resume. Name of employer: (required)From: (Month, Year) (required)To: (Month, Year) (required)Address: (required)Phone: (required)Position: (required)Supervisor: (required)Description of Duties: (required)Reason for Leaving: (required)Please use this space to cover any other previous employment, following the structure of the questions above.Are you a veteran of the United States Military Service? (required)YesNoIf yes, please state branch of service:Have you obtained any special skills or abilities as the result of service in the military?List three persons who have knowledge of your work performance. Please do not include relatives. Name: (required)Number of Years Acquainted: (required)Address:Telephone Number: (required)Position/Capacity in Which Known: (required)Name: (required)Number of Years Acquainted: (required)Address: (required)Telephone Number: (required)Position/Capacity in Which Known: (required)Name: (required)Number of Years Acquainted: (required)Address: (required)Telephone Number: (required)Position/Capacity in Which Known: (required)I hereby certify that the information contained in this application is true and correct to the best of my knowledge. I agree to have any of the statements checked by the Camarillo Health Care District (hereinafter referred to as the CHCD) unless I have indicated to the contrary. I authorize the references listed above, as well as all other individuals whom the CHCD contacts, to provide the CHCD any and all information concerning my previous employment and any other pertinent information that they may have. Further, I release all parties and persons from any and all liability for any damages that may result from furnishing such information to the CHCD as well as from the use or disclosure of such information by the CHCD or any of its agents, employees, or representatives. I understand that any misrepresentation, falsification, or material omission of information on this application may result in my failure to receive an offer or, if I am hired, my dismissal from employment. In consideration of my employment, I agree to conform to the rules and standards of the CHCD. I further agree that my employment and compensation can be terminated at-will, with or without cause, and with or without notice, at any time, either at my option or the option of the CHCD. I understand that no employee or representative of the CHCD, other than the Chief Executive Officer (CEO), has the authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing. Further, the CEO may not alter the at-will nature of the employment relationship unless the CEO and I both sign a written agreement that clearly and expressly specifies the intent to do so. I agree that this constitutes an integrated agreement with respect to the at-will nature of my employment relationship, that it is final and fully binding, and that there are no oral or collateral agreements regarding this issue. I also understand that all offers of employment are conditioned on the provision of satisfactory proof of an applicant’s identity and legal authority to work in the United States. By typing my name in the box provided, I understand I am providing a legal proxy for my signature. (required)Date:There was a problem saving your submission. Please try again later.Please wait while your submission is being saved...Submitting...SubmitThank you, your submission has been received.