Employment Application (Web Form) - Community Action Partnership of Madera County

COMMUNITY ACTION PARTNERSHIP OF MADERA COUNTY
1225 Gill Avenue
Madera, CA. 93637
Telephone: (559) 673-9173
Facsimile: (559) 673-2620
www.maderacap.org

EMPLOYMENT APPLICATION

The CAPMC is an equal opportunity employer. CAPMC provides equal employment opportunity to all persons regardless of race, national origin, religion, color, ancestry, physical disability, mental disability, medical condition, genetic information, marital status, sex, gender, gender identity, gender expression, transgender, sex stereotyping, age, sexual orientation, military status, veteran status, and any status protected by applicable federal, state and local laws.

Instructions:

Read position announcement thoroughly and understand all the minimum qualifications.
Answer all questions by writing clearly or typing in black/blue ink. Provide enough details to allow for full review and consideration. If an answer does not apply to you, write N/A.
Completely fill out the application and sign it.
Use a separate application when applying for more than one position.
Inquiry may be made of your former and current employers or schools regarding your performance records. Please provide the name and phone number of each contact on your application.
Please contact the Human Resources Office if you change your address or telephone number.
If you need any accommodation in the application or the testing process pursuant to the Americans with Disabilities Act (ADA), please call the Human Resources Office at (559) 673-9173.

Date

Full Name

Full Mailing Address

Primary Telephone

Secondary Telephone

Are you applying for?

Full-Time Work
Part-Time Work
Temporary Work

How did you hear about this job opening?

Have you ever applied to CAPMC before?

Have you ever worked for the CAPMC before?

Are you a Head Start parent or a CAPMC volunteer?

Have you ever been in the military? Furnish a DD 214 for consideration for verteran’s preferernce points.

Do you have any friends or relatives working at the CAPMC currently?

After reviewing the position announcement and physical requirement of the job for which you are applying, are you able to perform the essential functions of the job with or without reasonable accommodation?

Are you over 18 years of age?

If hired, can you submit proof of your legal right to work in the United States?

If hired, can you provide proof of possession of a valid California Driver’s License?

If hired, do you have a reliable and insurable transportation to and from work?

Have you ever been discharged from employment or been forced to resign?

Do You Have A High School Diploma?

If Yes, Name And Address Of The School:

If No, Did You Receive A GED?

Technical / Vocational / Business School

Selected Value: 0

Name And Address Of The School:

Course Of Study:

Certification/Degree Received:

Name And Address Of The School:

Course Of Study:

Certification/Degree Received:

University / College

Selected Value: 0

Name and Address of the School:

Major/Course of Study:

Units Completed:

Did you Graduate

If Yes, Date Degree Was Conferred

Name and Address of the School:

Major/Course of Study:

Units Completed:

Single Line Text

Did you Graduate:

If Yes, Date Degree Was Conferred:

Number of Early Child Development Units Completed:

Multiple Choice (copy) (copy) (copy) (copy)

First Choice
Second Choice
Third Choice

LICENSES – LIST APPLICABLE LICENSES AND CERTIFICATES INDICATED IN THE POSITION ANNOUNCEMENT

Selected Value: 0

LICENSE/CERTIFICATION NUMBER

ISSUE DATE

EXPIRATION DATE

LICENSE/CERTIFICATION NUMBER

ISSUE DATE

EXPIRATION DATE

SKILLS

Selected Value: 0

VERBAL LANGUAGE(S) FLUENCY IN

WRITTEN LANGUAGE(S) FLUENCY IN

TYPING NWPM

DICTATION/SHORTHAND WPM

CALCULATOR SPM

SOFTWARE PROGRAMS USED:

EMPLOYMENT HISTORY

Selected Value: 0

DATE STARTED

DATE ENDED

TITLE

SUPERVISOR NAME

HOURS PER WEEK

COMPANY/ORGANIZATION NAME

SUPERVISOR PHONE NUMBER

SALARY EARNED

COMPANY ADDRESS

LIST DUTIES PERFORMED

REASON FOR LEAVING

Multiple Choice (copy) (copy) (copy)

First Choice
Second Choice
Third Choice

DATE STARTED

DATE ENDED

TITLE

SUPERVISOR NAME

HOURS PER WEEK

COMPANY/ORGANIZATION NAME

SUPERVISOR PHONE NUMBER

SALARY EARNED

COMPANY ADDRESS

LIST DUTIES PERFORMED

REASON FOR LEAVING

Multiple Choice (copy) (copy)

First Choice
Second Choice
Third Choice

DATE STARTED

DATE ENDED

TITLE

SUPERVISOR NAME

HOURS PER WEEK

COMPANY/ORGANIZATION NAME

SUPERVISOR PHONE NUMBER

SALARY EARNED

COMPANY ADDRESS

LIST DUTIES PERFORMED

REASON FOR LEAVING

Multiple Choice (copy)

First Choice
Second Choice
Third Choice

DATE STARTED

DATE ENDED

TITLE

SUPERVISOR NAME

HOURS PER WEEK

COMPANY/ORGANIZATION NAME

SUPERVISOR PHONE NUMBER

SALARY EARNED

COMPANY ADDRESS

LIST DUTIES PERFORMED

REASON FOR LEAVING

CERTIFICATION

Selected Value: 0

CERTIFICATION

DATE

AGREEMENT

I ACCEPT

Multiple Choice (copy) (copy)

First Choice
Second Choice
Third Choice

REFERENCES

Selected Value: 0

FIRST NAME

LAST NAME

PHONE NUMBER

FULL ADDRESS

OCCUPATION

NUMBER OF YEARS KNOWN

Multiple Choice (copy) (copy)

First Choice
Second Choice
Third Choice

FIRST NAME

LAST NAME

PHONE NUMBER

FULL ADDRESS

OCCUPATION

NUMBER OF YEARS KNOWN

Multiple Choice

First Choice
Second Choice
Third Choice

FIRST NAME

LAST NAME

PHONE NUMBER

FULL ADDRESS

OCCUPATION

NUMBER OF YEARS KNOWN

CRIMINAL OFFENSE

If yes, state nature of the crime(s), when and where convicted, disposition of the case and any additional information you believe may be relevant.

DATE

AGREEMENT

I Accept

VOLUNTARY INFORMATION

Selected Value: 0

POSITION TITLE

NAME

VETERAN STATUS

DISABLED VETERAN: A veteran who served on active duty in the U.S. military and is entitled to disability compensation (or who but for the receipt of military retried pay would be entitled to disability compensation) under laws administered by the Sec
OTHER PROTECTED VETERAN: A veteran who served on active duty in the U.S. military during a war, or in a campaign or expedition for which a campaign badge was authorized under the laws administered by the Department of Defense.
RECENT SEPARATED VETERAN: A veteran separated during the three-year period beginning on the date of the veteran’s discharge or release from active duty in the U.S. military
ARMED FORCES SERVICE MEDAL VETERAN: A veteran who, while serving on active duty in the U.S. military, participated in a U.S. military operation that received an Armed Forces service medal.

AGE

UNDER 21
21-39
40-69
70 AND OVER

GENDER

MALE
FEMALE

ETHNICITY

AMERICAN INDIAN / ALASKA NATIVE: A person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community recognition
ASIAN: A person having origins in any of the original people of the Far East, Southeast Asian, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
BLACK / AFRICAN AMERICAN: A person having origins in any of the black racial group of Africa.
HISPANIC / LATINO: A person of Cuban, Mexican, Puerto Rican, South or Central America, or other Spanish culture or origin regardless of race.
NATIVE HAWAIIAN / OTHER PACIFIC ISLANDER: A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
WHITE: A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
TWO OR MORE RACES: All persons who identify with more than one of the above six races.