Name (required) Street Address (required) City (required) State (required) Zip Code (required) Home Phone Mobile Phone (required) Email (required) Position Applied For (required) Salary Desired Date Available to Start Work (required) If you are under age 18, can you provide a work permit if offered a job? (required) Can you, after employment, submit verification of your legal right to work in the U.S.? (required) Have you ever applied for a position or worked for the Camarillo Health Care District before? (required) If yes, specify dates (required) 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 (required) If yes, please specify the name under which you were employed or enrolled If you are employed now, may we contact your current employer? (required) Are you able to perform the essential duties of the position for which you are applying, either with or without reasonable accommodations? (required) If necessary, please indicate what type(s) of reasonable accommodations are needed (Please note that the District complies with the ADA and considers reasonable accommodation measures that may be necessary for eligible applicant/employees to perform essential job functions. Hire may be subject to passing a medical examination and/or skill agility tests.) 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.) Some of our clients do not speak English. Do you speak, write, or understand any foreign languages? (required) If yes, which language(s)? Do you have any friends or relatives working for the Camarillo Health Care District? (required) If yes, state name(s) and relationship(s) What prompted you to apply for employment with the Camarillo Health Care District; was it a referral? By whom? (required) Do we have your permission to distribute your application to other agencies? (required) Please answer the following questions if you are applying for a professional position: Are you licensed/certified for the job applied for? (required) If yes, Type of license/certification Issuing State/Agency License/certification number Has your license/certfication ever been revoked or suspended? If yes, state reason(s), date of revocation or suspension and date of reinstatement: Education: Do you have a High School Diploma or G.E.D? (required) Institution's Name (required) Name while attending (required) Registrar Phone Institution's Address (required) City and State (required) Zip Code (required) Education: Do you have a College/University degree? (required) List Degree/Major (required) Name while attending (required) Institution's Address (required) City and State (required) Zip Code (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: (required) Please list your computer hardware/software skills: (required) Employment History: Please list your present and past work experience for the last 10 years, beginning with your current job. You may include volunteer activities. You must complete this section even if you are attaching a resume. Please upload your resume here. (required) Name of most recent Employer: (required) Employer Address (required) Phone (required) Name & Title of Supervisor (required) Start Date and End Date (required) Position held (required) Description of Duties (required) Reason for Leaving (required) Name of Employer (required) Employer Address (required) Phone (required) Name & Title of Supervisor (required) Start date and End Date (required) Position held (required) Description of Duties (required) Reason for Leaving (required) Name of Employer (required) Employer Address (required) Phone (required) Name & Title of Supervisor (required) Start Date and End Date (required) Position held (required) Description of Duties (required) Reason for Leaving (required) Name of Employer Employer Address Phone Name & Title of Supervisor Start Date and End Date Position held Description of Duties Reason for Leaving Military Service: Are you a veteran of the United States Military Service? (required) If yes, please state branch of service Have you obtained any special skills or abilities as the result of service in the military? (required) If so, please describe List three persons who have knowledge of your work performance. Please do not include relatives. Reference Name (1) (required) Position/Capacity in which known (required) Address (required) Phone (required) Email (required) Number of Years Acquainted (required) Position/Capacity in Which Known (required) Reference Name (2) (required) Address (required) Phone (required) Email (required) Number of Years Acquainted (required) Reference Name (3) (required) Position/Capacity in which known (required) Address (required) Phone (required) Email (required) Number of Years Acquainted (required) By hitting the "Submit' button, 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 CHCD) unless I have indicated to the contrary. I authorize the references listed above, as well as all other individuals whom CHCD contacts, to provide 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 CHCD as well as from the use or disclosure of such information by 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 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 CHCD. I understand that no employee or representative of 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. Please enter your name and date to further acknowledge the statement. (required)
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