Casa Pacifica Employment Application

PERSONAL

LAST NAME     FIRST NAME     INITIAL
ADDRESS     CITY     STATE     ZIP
HOME PHONE     MOBILE     ARE YOU AT LEAST 21 YEARS OF AGE? YES
EMAIL ADDRESS

IF HIRED, YOU MUST BE ABLE TO FURNISH PROOF THAT YOU ARE A CITIZEN OR OTHERWISE LEGALLY PERMITTED TO WORK IN THE UNITED STATES. CAN YOU PROVIDE SUCH PROOF? YES     NO

EDUCATION AND SKILLS

HIGHEST GRADE COMPLETED:
HIGH SCHOOL 9 10 11 12 COLLEGE/UNIVERSITY 1 2 3 4 5+

	NAME OF SCHOOL	CITY, STATE	MAJOR	INDICATE DIPLOMA OR DEGREE OBTAINED
LAST HIGH SCHOOL
JR COLLEGE
COLLEGE OR UNIVERSITY
GRADUATE SCHOOL
VOCATIONAL/TRADE SCHOOL
OTHER

SPECIAL SKILLS YOU MAY POSSESS (PLEASE INCLUDE ANY SPECIAL SKILLS FROM MILITARY SERVICE):

OPTIONAL: LIST FOREIGN LANGUAGES IN WHICH YOU ARE FLUENT AND IN WHICH YOU ARE WILLING TO ASSIST IN TRANSLATION:

TYPING SPEED WPM: COMPUTER PROGRAMS USED:

LICENSE

MEDICAL/PROFESSIONAL LICENSE HELD:
REGISTRATION NUMBER STATE EXP. DATE

LICENSE HELD IN ANOTHER STATE:
REGISTRATION NUMBER STATE EXP. DATE

POSITION

HOW REFERRED    (IF NEWSPAPER, WHICH ONE)
POSITION APPLYING FOR
DO YOU HAVE ANY RELATIVES EMPLOYED WITH CASA PACIFICA? YES    NO   IF YES, WHO:

EMPLOYMENT STATUS PREFERENCE
REG. FULL-TIME    REG. PART-TIME    PER DIEM/ON-CALL: NUMBER OF HOURS REQUESTED/WEEK:

SHIFT PREFERENCE
SUN-WED   WED-SAT   MON-FRI    OTHER:

AVAILABILITY (CHECK ALL THAT APPLY)
DAYS ONLY    DAYS & EVENINGS    OVERNIGHTS    WEEKENDS   HOURS/WEEK DESIRED:

OVERTIME MAY BE REQUIRED FROM TIME TO TIME, DOES THIS POSE A PROBLEM FOR YOU? YES    NO
POPULATION PREFERENCE (BOYS, GIRLS, TEENS, PRESCHOOLERS):
DATE YOU WOULD BE AVAILABLE FOR WORK:    SALARY DESIRED:

EMPLOYMENT HISTORY

LIST PREVIOUS EMPLOYERS FOR WHOM YOU HAVE WORKED DURING THE LAST FIFTEEN YEARS, BEGINNING WITH THE MOST RECENT. ACCOUNT FOR ALL GAPS OF EMPLOYMENT. IF ADDITIONAL SPACE IS NEEDED, FAX ON A SHEET OF PAPER.

EMPLOYERS NAME     PHONE
ADDRESS     CITY     STATE     ZIP
JOB TITLE
SUPERVISORS NAME & TITLE
DESCRIPTION OF DUTIES

REASON FOR LEAVING OR PLANNING TO LEAVE
MAY WE CONTACT YES     NO
DATES EMPLOYED, FROM     TO
SALARY $     PER
FULL TIME     PART TIME, HOURS PER WEEK     PER DIEM, HOURS PER WEEK

HAVE YOU BEEN EMPLOYED WITH CASA PACIFICA BEFORE?
YES NO IF YES, SPECIFY DATES:
HAS ANY EMPLOYER EVER ASKED YOU TO RESIGN?
YES NO IF YES, EXPLAIN:

DRIVING

DO YOU HAVE A VALID DRIVER'S LICENSE? YES NO IF YES, INDICATE DRIVER'S LICENSE NUMBER:
STATE ISSUED DO YOU HAVE INSURANCE ON YOUR VEHICLE? YES NO
HAVE YOU EVER HAD YOUR DRIVER'S LICENSE REJECTED OR SUSPENDED WITHIN THE LAST 3 YEARS BECAUSE OF YOUR DRIVING RECORD? YES NO IF YES, EXPLAIN:
PLEASE LIST ALL THE MOVING VIOLATIONS AND ACCIDENTS WITHIN THE LAST 3 YEARS

GENERAL

1. TITLE 22 OF THE WELFARE AND INSTITUTIONS CODE REQUIRES THAT ALL EMPLOYEES HAVE A RECORD OF HEALTH EXAMS INCLUDING TB TESTS (OR CHEST X-RAYS) UPON EMPLOYMENT AND WHEN OTHERWISE REQUIRED BY THE STATE. DOES THIS POSE A PROBLEM FOR YOU? YES NO

2. IN COMPLIANCE WITH THE AMERICANS WITH DISABILITIES ACT, CASA PACIFICA CAN AND WILL EMPLOY PEOPLE WHO HAVE OR WHO HAVE HAD DISABILITIES. ARE YOU ABLE TO PERFORM THE ESSENTIAL JOB REQUIREMENTS OF THE POSITION FOR WHICH YOU ARE APPLYING? IF NO, WE CAN DISCUSS REASONABLE ACCOMMODATIONS. YES NO

3. HAVE YOU EVER BEEN CONVICTED OF A MISDEMEANOR OR FELONY? YES NO IF YES, EXPLAIN:

NOTE: THIS IS NOT AN AUTOMATIC BAR TO EMPLOYMENT.

MISSION, VISION, VALUES, ROLLS

AS A CASA PACIFICA EMPLOYEE, YOU WOULD BE REQUIRED TO SUPPORT AND UPHOLD THE EXPECTATIONS BELOW.

MISSION: Casa Pacifica provides hope and help for abused, neglected or at-risk children and their families.

VISION: Casa Pacifica will lead the services sector in promoting healthy outcomes for children and in strengthening families.

CORE VALUES:
VALUE #1: AT CASA PACIFICA, WE ARE COMMITTED TO TREATING EACH OTHER IN THE SAME WAY WE EXPECT CLIENTS TO BE TREATED. WHILE WE RECOGNIZE THAT ONE RELATIONSHIP IS "EMPLOYMENT" AND THE OTHER IS "TREATMENT," WE WILL STRIVE TO TREAT EACH OTHER AS WE EXPECT STAFF TO TREAT CLIENTS WITHIN THE REALM OF THE EMPLOYMENT RELATIONSHIP.

VALUE #2: AT CASA PACIFICA, WE BELIEVE ONE KEY TO MISSION SUCCESS IS DATA-BASED DECISION-MAKING. THIS MEANS MAKING THE BEST DECISION POSSIBLE IN LIGHT OF THE INFORMATION AVAILABLE. THEREFORE, ENSURING OPEN ACCESS TO QUALITY INFORMATION IS CRUCIAL TO THE DECISION MAKERS.

ROLES:
CASA PACIFICA HAS THREE EQUAL ROLE EXPECTATIONS OF ALL EMPLOYEES.
1. TO PERFORM THE TECHNICAL RESPONSIBILITIES FOR MY ASSIGNED POSITION IN TERMS OF BOTH QUALITY AND PRODUCTIVITY;
2. TO ACTIVELY AND CONSTRUCTIVELY PARTICIPATE AS A MEMBER OF ALL WORK TEAMS THE POSITION REQUIRES;
3. TO COMMIT AND ENGAGE IN THE PURSUIT OF CASA PACIFICA'S MISSION ON A DAILY BASIS.

FINGER PRINTING

TITLE 22 OF THE WELFARE AND INSTITUTIONS CODE REQUIRES THAT EMPLOYEES OF CASA PACIFICA SUBMIT A FINGERPRINT CARD TO THE LICENSING AGENCY FOR THE PURPOSE OF CONDUCTING A CRIMINAL RECORD REVIEW. DO YOU AGREE TO BE FINGERPRINTED? YES NO

DRUG SCREEN

AS PART OF YOUR APPLICATION FOR EMPLOYMENT WITH CASA PACIFICA, A DRUG SCREEN IS REQUIRED. DO YOU AGREE TO TAKE A DRUG SCREEN? YES NO

OTHER

OTHER FACTORS YOU WISH TO BE CONSIDERED:

OPTIONAL: SPECIAL TALENTS, HOBBIES AND SKILLS WHICH YOU WOULD BE WILLING TO TEACH (I.E. COOKING, PIANO, ETC.):

AGREEMENT

I HEREBY STATE THAT ALL THE INFORMATION GIVEN BY ME IN THIS APPLICATION IS TRUE IN ALL RESPECTS. I UNDERSTAND THAT IF I AM EMPLOYED AND THE INFORMATION IS FOUND TO BE FALSE IN ANY RESPECT, I WILL BE SUBJECT TO DISMISSAL WITHOUT NOTICE AT ANY TIME. I HEREBY AUTHORIZE AND HOLD HARMLESS MY FORMER EMPLOYERS TO RELEASE INFORMATION PERTAINING TO MY WORK RECORD, MY WORK HABITS, AND MY WORK PERFORMANCE WHILE IN THEIR EMPLOY. IN MAKING APPLICATION FOR EMPLOYMENT, I UNDERSTAND THAT AN INVESTIGATIVE REPORT MAY BE MADE BY A CONSUMER REPORTING AGENCY TO INCLUDE INFORMATION AS TO MY CHARACTER, GENERAL REPUTATION, AND PERSONAL CHARACTERISTICS, WHICHEVER MAY BE APPLICABLE. IF SUCH AN INVESTIGATIVE REPORT IS MADE, I UNDERSTAND THAT I WILL RECEIVE NOTICE THAT SUCH A REPORT HAS BEEN REQUESTED, AND THAT I WILL HAVE THE RIGHT TO MAKE A WRITTEN REQUEST FOR A COMPLETE AND ACCURATE DISCLOSURE OF ADDITIONAL INFORMATION CONCERNING THE NATURE AND SCOPE OF THE INVESTIGATION. I UNDERSTAND AND AGREE THAT ANY EMPLOYEE HANDBOOK OR OTHER WRITTEN POLICIES THAT I MAY RECEIVE WILL NOT CONSTITUTE AN EMPLOYMENT CONTRACT, BUT WILL BE MERELY A GRATUITOUS STATEMENT OF THE AGENCY'S THEN-CURRENT POLICIES. I UNDERSTAND THAT CASA PACIFICA RESERVES THE RIGHT TO REQUIRE ITS EMPLOYEES TO SUBMIT TO PHYSICAL SAND MENTAL EXAMINATIONS, INCLUDING BLOOD TESTS OR URINALYSIS FOR ALCOHOL OR DRUG SCREENS, AND TO INSPECT BAGS (INCLUDING PURSES OR BRIEFCASES) OR PARCELS BROUGHT INTO OR TAKEN OUT OF THE PREMISES. I UNDERSTAND THAT REFUSAL TO SUBMIT TO A PHYSICAL OR MENTAL EXAMINATION, URINALYSIS, BLOOD TEST, 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 FOR NO DEFINITE TERM AND THAT EITHER I OR THE EMPLOYER 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 EXECUTIVE DIRECTOR. I FURTHER UNDERSTAND THAT MATERIAL OMISSION OR MISREPRESENTATION OF PERTINENT FACTS MAY RESULT IN MY IMMEDIATE TERMINATION OR WITHDRAWAL OF AN OFFER.

SIGNATURE DATE