Fillable APPLICATION FOR EMPLOYMENT

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APPLICATION FOR EMPLOYMENT

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Page 1 of 9 (OCHS Online Application for Employment)
APPLICATION FOR EMPLOYMENT
2501 SOUTH PULLMAN STREET, SUITE 100 ● SANTA ANA, CA 92705
(714) 241-8920 FAX (949) 596-8291
www.ochsinc.org ● jobs@ochsinc.org
ATTENTION APPLICANT - PLEASE READ THE FOLLOWING BEFORE COMPLETING THE APPLICATION:
1. This application must be typewritten or completed in ink.
2. Please print or write clearly.
3. Answer every question applicable to the job for which you are applying. A resume may be attached but does
not substitute for completion of all questions. An unanswered question may be considered a reason for disregarding your
application.
4. Any omission of facts or misrepresentation on your application is cause for disqualification or dismissal. Applications with
missing data may be disregarded without notice to the applicant.
5. You must be specific regarding the position you are applying for. The most common entry level positions are: Family
Engagement Advocate, Food Service Assistant, Teacher or Teacher Assistant.
6. Read the "Terms of Employment" section, and be sure to sign the application.
7. After completing the application, you may forward it to Orange County Head Start, Inc. by:
Mailing it to the address listed above
Hand deliver to the address above
Email to jobs@ochsinc.org
Fax to (949) 596-8291.
NOTE: ALL APPLICATIONS HAND DELIVERED MUST BE GIVEN DIRECTLY TO A STAFF MEMBER IN THE HUMAN RESOURCES
DEPARTMENT OR PLACED IN THE HR BOX AT THE RECEPTION DESK.
NOTIFICATION TO PROSPECTIVE EMPLOYEES
Applicants for all positions at Orange County Head Start, Inc. are required to sign a release and be submitted to a urine drug
screen at a clinic designated by OCHS. This procedure occurs after the interviewing process post offer, pre-start date. Orange
County Head Start, Inc. will rescind the offer of employment to any person who tests positive for illegal drugs.
Page 2 of 9 (OCHS Online Application for Employment)
APPLICATION FOR EMPLOYMENT
2501 SOUTH PULLMAN STREET, SUITE 100 ● SANTA ANA, CA 92705
(714) 241-8920 FAX (949) 596-8291
www.ochsinc.org ● jobs@ochsinc.org
ATTENTION APPLICANTS: Any omission of facts or misrepresentation on your application is cause for disqualification from hire or
termination following hire. Applications with missing data will not be returned to the applicant.
OCHS is an Equal Opportunity Employer. All applicants will be considered for employment regardless of race, religious creed, color,
ancestry, marital status, medical condition, disability, national origin, age, sex, wage, gender, pregnancy or related medical condition,
or political affiliation.
POSITION DESIRED: ____________________________________________________________________________
(
A separate application is required for each position
.)
PERSONAL DATA: Please print in ink or type only.
Last Name
First Name
Middle Initial
Telephone Home:
Cell:
Street Address
Unit/ Apt No.
Telephone Work:
Email:
City
Zip
Social Security Number:
If hired, can you provide proof of identity and legal
authorization to work in the U.S.?
Yes No
Do you have proof of vehicle insurance?
Yes No
Driver's License Number:
State:
Expiration Date:
Relatives employed with ORANGE COUNTY HEAD START, INC.:
Are you related to any employee or member of the Orange County Head Start, Inc., Board of
Directors? Yes No
If YES, please provide the information below:
Name:
Relationship:
Work location:
Have you worked for OCHS in the past?
Yes No If yes, please answer...
Position:
Dates of employment:
From: To:
Name, if different:
Mo:
Yr:
Mo:
Yr:
Page 3 of 9 (OCHS Online Application for Employment)
Criminal Record:
(If you answer yes to any of these questions, complete details must be outlined and attached to this application on a separate piece of paper. Include
offenses, places, dates, and penalties. Do not list minor traffic infractions or list convictions for which the record has been judicially sealed, expunged or statutorily eradicated;
convictions for which probation has been successfully completed or otherwise discharged and the case has been dismissed; referrals to and participation in any pre-trial or post-
trial diversion programs; and marijuana related offenses that occurred over two years ago.)
A conviction, guilty plea or no contest will not necessarily disqualify an applicant from
consideration.
Have you pled guilty or no contest or been convicted of any offense which would prohibit you from working with children?
Yes No
EDUCATION AND PROFESSIONAL TRAINING:
Name of School
Address, City and State Only
Units Completed
Major/Minor
Degree Received
High School:
College/University:
College/University:
Graduate School:
Other:
Credentials and completed applicable courses: List all valid California credentials you hold. If you have a credential application in process, list
credential(s) applied for and date application was submitted. List all courses completed which are applicable to your desired position. (List completed courses only). Attach a
complete copy of all credentials, application for credentials, and/or transcripts, originals may be required. All copies previously mentioned must accompany
your application in order for it to be accepted.
Professional License and Certification:
Name of License/ Certification:
Issuing State:
Number:
Has your License/ Certification ever been revoked?
Yes No If yes, . . .
Reason for revocation:
Revocation Date:
Reinstatement Date:
Page 4 of 9 (OCHS Online Application for Employment)
Military service record and reserve status:
Military Service:
Yes No
Reserves:
Yes No
Branch:
Rank:
Years of Service:
Honorable Discharge:
Yes No
Skills received that may apply to this position:
Language Skills: List languages other than English, including sign language.
Language
Speak fluently?
Write fluently?
Yes No
Yes No
Yes No
Yes No
List any equipment you can operate that may be involved in your desired position.
References: List people we may contact who are qualified to evaluate your capabilities (do not include relatives):
Name:
Address:
Telephone:
Occupation:
Years Known:
Name:
Address:
Telephone:
Occupation:
Years Known:
Name:
Address:
Telephone:
Occupation:
Years Known:
Page 5 of 9 (OCHS Online Application for Employment)
EMPLOYMENT HISTORY as complete as possible: 1) Information must be complete. Incomplete information will cause your application to be disregarded. 2)
List chronologically, most recent first. 3) List promotions separately. 4) Attach a resume if available. Do not submit a resume in place of completing this section. (Use an
additional sheet if more space is needed.)
Job Title:
From –
To
Month:
Year:
Month:
Year:
Name of Employer:
Telephone No:
Street Address:
City:
State:
Zip:
Supervisor's Name:
Job Title:
Telephone No:
Reason For Leaving: May we contact this employer?
Yes No
Briefly describe duties performed and skills utilized:
Job Title:
From –
To
Month:
Year:
Month:
Year:
Name of Employer:
Telephone No:
Street Address:
City:
State:
Zip:
Supervisor's Name:
Job Title:
Telephone No:
Reason For Leaving: May we contact this employer?
Yes No
Briefly describe duties performed and skills utilized:
Page 6 of 9 (OCHS Online Application for Employment)
EMPLOYMENT HISTORY (Continued…)
Job Title:
From –
To
Month:
Year:
Month:
Year:
Name of Employer:
Telephone No:
Street Address:
City:
State:
Zip:
Supervisor's Name:
Job Title:
Telephone No:
Reason For Leaving: May we contact this employer?
Yes No
Briefly describe duties performed and skills utilized:
Job Title:
From –
To
Month:
Year:
Month:
Year:
Name of Employer:
Telephone No:
Street Address:
City:
State:
Zip:
Supervisor's Name:
Job Title:
Telephone No:
Reason For Leaving: May we contact this employer?
Yes No
Briefly describe duties performed and skills utilized:
Page 7 of 9 (OCHS Online Application for Employment)
AVAILABILITY:
I am available for:
Full-time Employment Part-time Employment Substitute
Use this section to continue your employment history or to describe in great detail any Volunteer Experience and/or Related
Activities that are appropriate for your desired position. Please include dates and location of any Head Start experience-volunteer or
parental. Attach a separate sheet if needed.
Page 8 of 9 (OCHS Online Application for Employment)
Any offer of employment with Orange County Head Start, Inc. is contingent upon child abuse clearance, criminal
record clearance and Department of Justice clearance check, as well as a medical examination (including a TB Test), a
drug test, and in some instances insurability under our Company Auto Insurance Policy. Until all pre-employment
procedures are completed, any offers of employment are conditional and preliminary and may be withdrawn at any
time.
APPLICANT AUTHORIZATION AND ATTESTATION:
My signature below authorizes Orange County Head Start, Inc., to conduct a background investigation concerning any and all
information bearing on my suitability for employment. Further, I authorize any person, agency, or other entity contacted by Orange
County Head Start, Inc., to release any information to OCHS with respect to my application for employment. I waive my right of
access to any such information released to OCHS and, without limitation, hereby release OCHS and any person, agency, or entity
which releases information from any liability in connection with such release of information or its authorized use.
I hereby certify under penalty of perjury that all of the information I have provided on this Employment Application is true, correct,
with the knowledge that such statements and information may be relied upon by Orange County Head Start, Inc., in considering my
application for employment. I understand that any omission or false statement made by me on this application, or any supplement to
it, or in the course of any interview for employment, may result in denial of employment or termination of employment should I
become employed by OCHS.
I expressly agree and understand that if I am employed, my employment will be at-will, for no definite or determinable period.
Therefore, my employment may be terminated at any time, with or without prior notice, for any or no reason, with or without cause,
at the option of either the company or myself. Additionally, the terms of my employment at the company, including but not limited to,
promotion, demotion, discipline, layoff, transfer, compensation, benefits, duties and location of work, may be changed by the
company at any time, with or without notice. I expressly understand and agree that the at-will nature of my employment cannot be
changed, modified, amended or rescinded except by an individual written agreement signed by me and the Executive Director of
OCHS.
Print name of applicant:
Signature: ____________________________________________________________ Date: _______________________
Click Here to Print and Sign
Page 9 of 9 (OCHS Online Application for Employment)
In compliance with the Federal Equal Employment Opportunity (EEO) requirements, Orange County Head Start, Inc. requests that applicants
voluntarily provide the following information. Please check below the appropriate categories.
This is not a part of the selection process.
All
information will be treated confidentially.
This form will be separated before the application is used in any phase of the selection process.
This information may be provided to State and Federal Regulatory Agencies.
Name:
(Optional)
A. Ethnicity
(1) Anglo, Caucasian
(2) Black, African-American
(3) Hispanic, Latino
(4) Asian, Asian American, Pacific Islander
(5) Native American Indian, Native Alaskan
(6) Other
B. Age Sex
(1) Under 40 (1) Male
(2) 40 or over (2) Female
Government contractors must take affirmative action to employ and advance certain qualified individuals subject to the Rehabilitation Act of 1973 and the
Vietnam Era Veterans Readjustment Act of 1974. Completion of the following information is voluntary, and will assist us in proper placement and reasonable
accommodation. If you wish to be identified as qualifying for such placement or accommodation, please check where applicable:
Vietnam Era Veteran
Disabled Veteran
Individual with a Disability
C. The following information is used to measure the effectiveness of our recruiting efforts. We would like you to tell us how you heard
about this position:
(1) Orange County Head Start, Inc. employee (4) Friend
(2) Relative (5) Self Directed
(3) Newspaper (6) Other:
(which one)
TO BE COMPLETED BY ORANGE COUNTY HEAD START, INC.
EEO - 1 Category: 1. Officials and managers 6. Crafts - skilled
2. Professionals 7. Operatives - semi-skilled
3. Technicians 8. Laborers - unskilled
4. Sales 9. Service Workers
5. Office and clerical
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APPLICATION FOR EMPLOYMENT

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Completed 27 September 2021

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