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An Equal Opportunity Employer Application for Employment Personal

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HR – Form – Employment Application - Revised June 2020
An Equal Opportunity Employer
Application for Employment
Personal Information
Name (Last Name, First)
Other Last Names Used
Social Security No.
XXX – XX -
Present Address
Apt. No.
City
State
Zip
Permanent Address
Apt. No.
City
State
Zip
Are you 18 years or older?
Yes / No
Email Address
Do you possess a valid
Driver’s License?
Yes / No
If yes, provide
Driver’s License #
State
Expiration Date
Can you provide at least 3
years of verifiable driving
history? Yes / No
Do you have any relatives currently or formerly employed with Villa Esperanza Services? If so,
please state name, department and nature of relationship:
__________________________________________________________________________________
__________________________________________________________________________________
If hired, are you able to supply legal verification of your right to work in the United States?
Yes No
Position applying for
Date you can start
Salary desired
Shifts/Schedule you can work:
Full Time Part Time Days Evenings Nights Weekends
Are you currently employed?
Yes No
If yes, may we inquire of your present employer?
Yes No
Have you ever applied for employment with
Villa Esperanza Services before?
Yes No
Where?
When?
Have you ever worked for Villa Esperanza
Services before?
Yes No
Where?
When?
Reason for leaving Villa Esperanza Services
Name of last supervisor at Villa Esperanza Services
Who referred you to this company?
Employment Agency Newspaper Ad Villa Banner/Villa Vehicle
Friend/employee; name: _______________________________________
State Employment Agency College Placement Service Walk-in
Other – please explain: ________________________________________
HR – Form – Employment Application - Revised June 2020
Education & Training
School Level Name and Location of School
No. of
Years
Attended
Did you
Graduate? Subjects Studied
High School
Yes / No
College Yes / No
Trade, Business
or
Correspondence
School
Yes / No
Subjects of special study or research work/Special Training/Special Skills:
Villa Esperanza Services is an equal opportunity employer and makes employment decisions on the
basis of merit. We want to have the best available persons in every job. Agency policy prohibits
unlawful discrimination based on race, color, creed, sex, religion, marital status, age, national origin or
ancestry, physical or mental disability, medical condition, sexual orientation, and any other
consideration made unlawful by federal, state and/or local laws.
HR – Form – Employment Application - Revised June 2020
Former Employers - Please provide seven years of employment history starting with the most recent
employer and explain any lapse of employment and provide feedback regarding your skill set experience.
Name of present or last Employer
Address
City
State
Zip
Starting Date
Leaving Date
Job Title
May we contact your Supervisor? Yes / No
Name of Supervisor
Title
Phone Number
Description of Work
Reason for Leaving
Name of present or last Employer
Address
City
State
Zip
Starting Date
Leaving Date
Job Title
May we contact your Supervisor? Yes / No
Name of Supervisor
Title
Phone Number
Description of Work
Reason for Leaving
Name of present or last Employer
Address
City
State
Zip
Starting Date
Leaving Date
Job Title
May we contact your Supervisor? Yes / No
Name of Supervisor
Title
Phone Number
Description of Work
Reason for Leaving
HR – Form – Employment Application - Revised June 2020
References
Below, give the names of three persons you are not related to, whom you have known at least one year.
Name
Phone Number
Business
1
2
3
Unpaid Experience
Have you obtained any special skills or abilities (relevant to the position for which you are applying)
as a result of service in the military, volunteer assignment, etc.?
Yes (if yes, describe below) No
Villa Esperanza Services operates licensed facilities for Developmentally Disabled clients. State law
requires that persons associated with licensed facilities be fingerprinted and disclose any
convictions. A conviction is any plea of guilty or nolo contendere (no contest) or a verdict of guilty.
The fingerprints will be used by licensing entities to obtain information about your criminal history.
Have you ever been convicted of any crime (felony or misdemeanor) OTHER THAN (1) a
marijuana related conviction that occurred more than two years ago; (2) an offense for which you
were referred to, and participated in, any pre-trial or post trial diversion program and (3) any
criminal history, including arrests, detention, process, diversion, supervision, adjudication, or court
disposition that occurred while you were subject to the process or jurisdiction of juvenile
court law? Yes No
If yes, provide date of incident/conviction and details. (A conviction will not necessarily exclude
you from consideration. Factors such as level, date, and job correlation will be considered.)
HR – Form – Employment Application - Revised June 2020
Authorization
I certify that all the facts contained in this application (and accompanying resume, if any) are true and
complete to the best of my knowledge. I understand that any false statement, omission, or
misrepresentation on this application (and accompanying resume, if any) is sufficient cause for
refusal to hire or dismissal if I have been employed, no matter when discovered by Villa Esperanza
Services. __________ (Initials)
I understand that any employment is contingent on a background check. I authorize Villa Esperanza
Services to thoroughly investigate all statements contained in my application or resume, and I
voluntarily and knowingly authorize my former/current employers and references to disclose
information regarding my former employment, character and general reputation to the Company,
without giving me prior notice of such disclosure. In addition, I release Villa Esperanza Services,
any former employers and all references listed above from any and all claims, demands or liabilities
arising out of or related to such investigation or disclosure. __________ (Initials)
I understand and acknowledge that if I am offered employment with Villa Esperanza Services, my
employment will be contingent upon satisfactory completion of a post-offer process which includes
a live-scan (fingerprinting) process, background check, physical, and tuberculosis clearance. I further
understand and acknowledge that failure to satisfactorily complete all levels of the post-offer process
will cause any offer of employment to be rescinded._________ (Initials)
I understand and acknowledge that if hired, my live-scan (fingerprinting) clearance from the Federal
Bureau of Investigations (FBI) and Department of Justice (DOJ) must remain active and cleared at
all times during my employment with Villa Esperanza Services and that my continued employment
with the Agency is governed by such clearance. I further understand and acknowledge that if hired
and if my live-scan (fingerprinting) clearance is compromised or revoked by the governing
authorities, my employment status with Villa Esperanza Services will be jeopardized and I may be
subject to disciplinary action up to and including termination of employment. ______ (Initials)
If hired, I agree to abide by all of Villa Esperanza Services work rules, policies and procedures. Villa
Esperanza Services retains the right to revise its policies or procedures, in whole or in part, at any
time. __________ (Initials)
I understand and agree that nothing contained in this application, or conveyed during any interview,
is intended to create an employment contract. I further understand and agree that if I am hired, my
employment will be “at will” and without fixed term, and may be terminated at any time, with or
without cause and without prior notice, at the option of either myself or Villa Esperanza Services.
__________ (Initials)
________________ ___________________________ ______________________________
Date Name Signature
HR – Form – Employment Application - Revised June 2020
2116 East Villa Street ▪ Pasadena, CA 91107 ▪ (626) 449-2919
Acknowledgment Form
Live-scan/Fingerprinting Clearance
_______________________________________________________
I understand and acknowledge that if I am offered employment with Villa Esperanza Services;
my employment will be contingent upon satisfactory completion of a post-offer process which
includes a live-scan (fingerprinting) process, background check, physical, and tuberculosis clearance.
________ (Initials)
I understand and acknowledge that failure to satisfactorily complete all levels of the post-offer
process will cause any offer of employment to be rescinded. _______ (Initials)
I understand and acknowledge that my live-scan (fingerprinting) clearance from the Federal
Bureau of Investigation (FBI), Department of Justice (DOJ) must remain active, cleared, and
associated at all times with the required licensing entities (Department of Health (DOH), Department
of Social Services (DPSS), Community Care Licensing (CCL), etc.) during my employment with
Villa Esperanza Services and that my continued employment with the Agency is governed by such
clearance.________ (Initials)
I understand and acknowledge that if my live-scan (fingerprinting) clearance is compromised
or revoked by the governing authorities, my employment status with Villa Esperanza Services will
be jeopardized and I may be subject to disciplinary action up to and including termination of
employment. ________ (Initials)
Furthermore, I understand that employment with Villa Esperanza Services is not for a specific
term and is at the mutual consent of the employee and Villa Esperanza Services. Accordingly, either
the employee or Villa Esperanza Services can terminate the employment relationship at-will, with or
without cause, at any time. ________ (Initials)
________________ ___________________________ ______________________________
Date Name Signature
HR – Form – Employment Application - Revised June 2020
Villa Esperanza Services
Supplemental Employment Application Questions
Name: ____________________________________________ Date: ___________________
Briefly answer the following questions:
1. Have you ever worked with individuals with Developmental Disabilities?
Yes
No
a. If yes, describe the type(s) of disability (ies) and to what extent.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
b. If no, describe the type of special training/skills that you possess for working with
this population?
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
2. Do you possess a valid CA Driver’s License?
Yes
No
3. Would you have any objections to changing diapers for adults, bathing adults and
assisting adults with basic living skills?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
4. What would you do if you were working with your assigned client and he or she
begins to exhibit a behavior episode (hit/kick/bite you)?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
5. When we speak with your former supervisor(s), what are some of the things that they
will tell us about you?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
All potential employees will be required to satisfactorily complete our post-offer
process consisting of a TB, physical, and fingerprinting clearance.
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An Equal Opportunity Employer Application for Employment Personal

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Completed 20 May 2021

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