Name (required)
Street Address (required)
City (required)
State (required)
Home Telephone
Cellphone (required)
Email (required)
Position Applied For (required)
Salary Desired
Date Available to Start Work (required)
If applying for temporary work, during what period of time will you be available?
If yes, specify dates (required)
If yes, please specify the name under which you were employed or enrolled
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.)
If yes, which language(s)?
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)
Type of license/certification
Issuing State/Agency
License/certification number
If yes, state reason(s), date of revocation or suspension and date of reinstatement:
List the Name and Address of High School or G.E.D (required)
List Degree/Major (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 much 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)
Telephone (required)
Name & Title of Supervisor (required)
Dates of Employment (required)
Position held (required)
Description of Duties (required)
Reason for Leaving (required)
Name of Employer (required)
Employer Address (required)
Telephone (required)
Name & Title of Supervisor (required)
Dates of Employment (required)
Position held (required)
Description of Duties (required)
Reason for Leaving (required)
Name of Employer (required)
Employer Address (required)
Telephone (required)
Name & Title of Supervisor (required)
Dates of Employment (required)
Position held (required)
Description of Duties (required)
Reason for Leaving (required)
Name of Employer
Employer Address
Telephone
Name & Title of Supervisor
Dates of Employment
Position held
Description of Duties
Reason for Leaving
If yes, please state branch of service
If so, please describe
List three persons who have knowledge of your work performance. Please do not include relatives.
Reference Name (1) (required)
Reference Address (required)
Reference Telephone (required)
Number of Years Acquainted (required)
Position/Capacity in Which Known (required)
Reference Name (2) (required)
Reference Address (required)
Reference Telephone (required)
Number of Years Acquainted (required)
Position/Capacity in Which Known (required)
Reference Name (3) (required)
Reference Address (required)
Reference Telephone (required)
Number of Years Acquainted (required)
Position/Capacity in Which Known (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 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. Please enter your name and date to further acknowledge the statement. (required)
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