Application For Employment

Completion of this form is a part of the Agency's application process. All requested information must be completed on the application form itself. Resumes or attachments may be included, but cannot be substituted for an application form. Failure to complete the application accurately may disqualify an individual from being considered for a position, or if hired, may result in termination of employment. Additionally, if the Agency extends you an offer of employment, it will be contingent upon: 1) your passing a physical exam to verify your ability to perform the essential job functions, 2) a negative PPD or chest x-ray, 3) a negative drug test, 4) fingerprint clearance from the department of justice, and 5) proof of automobile insurance coverage.

Personal Information

Name (Last, First, Middle):  

Today's Date (mm/dd/yyyy):

Address:  

City:  

State:

Zip Code:

Social Security Number:

Home Phone:

Cell/Work Phone:

If hired, when can you start work?

Have you been previously employed by RYGCA or Vista Guidance Centers? yes-Previously Employed no Previous Employment

Name (if different) while employed previously:

Dates of previous employment:

Do you have any friends or relatives employed here?

Name(s):

Relationship(s):

Position applied for:

Full-time: Part-time: Intern: Temp:

Hours desired (if applicable):

Person to Notify in case of an emergency

Last Name:

First Name:

Address/P.O. Box:

City:

State:

Zip Code:

Telephone (include area code):

Would you be willing to work overtime? Yes No

List any other name by which you have been known for the purpose of employment and licensure:

Professional California License(s) or Certification:

Number:

Expiration Date:

Can you, after receiving an offer of employment, submit:

Proof of your legal right to work in the U.S.? yes no

Proof that you are at least 18 years of age? yes no

Have you ever been convicted of any crime other than a minor traffic violation? (A conviction is not an automatic bar to employment. Each case will be considered on it's own merits.) yes no

If yes, please explain and state the charge, the court, the date, and disposition of the case:

Are there any arrests or criminal proceedings currently pending against you? (A pending arrest or criminal proceeding is not at automatic bar to employment. Each case will be considered on its own merits.) yes no

If yes, please explain:

General

Do you have a valid California Driver's License? yes no

License Number:

We are interested to know how you were referred to Vista Guidance Centers. Please check the appropriate areas below:

Referred by (employee's name):

Classified ad in:

The Sun

Press Enterprise

Redlands Daily Facts

Other (specify):

Professional Journal (specify):

Internet / Website

Education

Skills and Education (check highest grade completed):

8 9 10 11 12

School:

Location:

From Month / Year:

To Month / Year:

No. of Units Completed:

Degree or Diploma:

GPA:

College:

1 2 3 4

School:

Location:

From Month / Year:

To Month / Year:

No. of Units Completed:

Degree or Diploma:

GPA:

Major:

Graduate:

1 2 3 4

School:

Location:

From Month / Year:

To Month / Year:

No. of Units Completed:

Degree or Diploma:

GPA:

Major:

Special Certifications

Are you certified in CPR/BLS? Yes No Application in progress

If yes, expiration date:

Are you certified in First Aid? Yes No Application in progress

If yes, expiration date:

Office Skills

Do you type? Yes No

If yes, typing speed (WPM):

Check other skills:

Data Entry Letter Composition Copier / Fax Machine

10-key Adding Machine Other:

Computer Skills

Do you have experience in the use of a personal computer? Yes No

Check other skills:

Word Excel Access Power Point

E-mail Calendar Clinical Documentation

Other:

Brief Description:

Employment Record for the Past Ten Years: Begin With Your Most Recent Employer

DO NOT OMIT ANY EMPLOYMENT.

Are you presently employed? Yes No

May we contact your present employer? Yes No

Employer 1:

Company Name:

Address:

City:

State:

Zip Code:

Your Job Title:

Your Duties:

Dates:
From:

To:

Hours worked per week:

Salary:
Starting pay:

Last pay:

Type of Business:

Name of Your Immediate Supervisor:

Supervisor's Phone Number:

Reason for Leaving:

Employer 2:

Company Name:

Address:

City:

State:

Zip Code:

Your Job Title:

Your Duties:

Dates:
From:

To:

Hours worked per week:

Salary:
Starting pay:

Last pay:

Type of Business:

Name of Your Immediate Supervisor:

Supervisor's Phone Number:

Reason for Leaving:

Employer 3:

Company Name:

Address:

City:

State:

Zip Code:

Your Job Title:

Your Duties:

Dates:
From:

To:

Hours worked per week:

Salary:
Starting pay:

Last pay:

Type of Business:

Name of Your Immediate Supervisor:

Supervisor's Phone Number:

Reason for Leaving:

Employer 4:

Company Name:

Address:

City:

State:

Zip Code:

Your Job Title:

Your Duties:

Dates:
From:

To:

Hours worked per week:

Salary:
Starting pay:

Last pay:

Type of Business:

Name of Your Immediate Supervisor:

Supervisor's Phone Number:

Reason for Leaving:

List ANY periods of unemployment during the past ten years, beginning with the most recent period of unemployment.

1:

From:

To:

Reason For Unemployment:

2:

From:

To:

Reason For Unemployment:

3:

From:

To:

Reason For Unemployment:

4:

From:

To:

Reason For Unemployment:

Professional References (Please do not list relatives)

1:

Name:

Occupation:

Address:

City:

State:

Zip Code:

Phone Number:

2:

Name:

Occupation:

Address:

City:

State:

Zip Code:

Phone Number:

Self Description
In the space provided below, you are asked to describe yourself in your own words without any attempt to be modest. Describe your strengths and weaknesses that may affect your ability to succeed in the position for which you have applied. Why do you think you are qualified for this position?

Conditions Of Employment

Vista Guidance Centers (VGC) is an equal opportunity employer and is committed to making hiring and other employment related decisions without regard to an individual's race, color, creed, sex, sexual orientation, national origin, ancestry, citizenship, age, handicap or disability (including pregnancy), religion, marital status, or any other legally protected status.

I certify that the information in the employment application and any related documents that I am submitting is correct to the best of my knowledge. I understand that falsification of this information is grounds for refusal to hire or, if hired, termination. I authorize any of the persons or organizations noted in the application to give BGC any and all information concerning my previous employment, education, or other information they might have, personal or otherwise, with regard to any of the subjects covered by this application. I authorize VGC to request and receive such information and release VGC and all such parties from all liability for any damage that may result from furnishing such information to VGC, its agents and representatives.

I agree, that if hired, I will follow the rules, regulations, and policies of VGC and acknowledge that these rules, regulations, and policies may be changed, integrated, deleted, or added to at any time without any prior notice to me. This may include, but are not limited to, overtime, rotating or changing work assignments, locations and schedules, drug testing, weekend and night work, and other conditions that may not necessarily meet with my individual preferences.

I am applying for employment with VGC. I understand and agree that, if hired, my employment would not be for a definite term or period of time, and would be at-will. I understand that under this at-will employment status, I may be terminated at anytime without any obligation on VGC's part to provide cause or justification. By accepting employment, if offered, with VGC, I agree to this at-will employment status. Finally, I understand that any offer of employment will be based on, among other things, my signing a written acknowledgement agreeing that my employment is at-will.

I further agree that my employment, if offered, is subject to 1) a physical examination to determine if I am physically and otherwise fit to perform the essential functions for the position for which I am being considered, 2) a negative PPD (or chest x-ray), 3) fingerprinting and clearance from the Department of Justice, and 4) a negative drug test. I hereby agree that the results of all the above shall be released to representative of VGC.

Proof of identity and lawful status to work in the United States is also required as a condition of any offered employment.

I acknowledge and agree that my employment with VGC may require that I use my own vehicle for transportation to and from assignments. I agree to furnish VGC with a copy of my automobile insurance indicating property and liability coverage.

Applicants whose jobs require driving must have a driver's license valid in California and could be subject to a Department of Motor Vehicles check prior to employment and as a basis of continued employment. I agree with and consent to all of the above as VGC considers me for employment.

Date:

Signature / Name: