Fillable Community Action Partnership of San Bernardino County (CAPSBC)

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Community Action Partnership of San Bernardino County (CAPSBC)

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  • 23 check-boxes
  • 176 other fields

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Page 1 of 7
Community Action Partnership of San Bernardino County (CAPSBC) is the designated Community Action
Agency for San Bernardino County. CAPSBC shall not discriminate in its hiring and personnel procedures
against any applicant for employment or any employee because of race, religion, color, sex, gender identity,
sexual orientation, national origin, ancestry, citizenship status, uniform service member status, marital status,
pregnancy, age, protected medical condition, disability, genetic information or any other protected status in
accordance with all applicable federal, state and local laws.
Candidates for interviews will be initially considered through an evaluation of their application. Applicants are
encouraged to attach resumes and/or other information which will assist CAPSBC in the evaluation of the
applicant's qualifications. Education and/or experience will be considered only as it most directly relates to
the position applied for. Each applicant will be notified by mail and/or phone if he/she is or is not selected for
an interview and/or employment. Following the hiring interviews, a background check will be conducted on
the candidate(s) being considered for employment. After the background check is completed, a conditional
offer of employment will be made to the recommended applicant for hire contingent upon applicant passing a
pre-employment physical examination only to include urine drug testing and TB screening. Newly hired
employees will be required to provide proof of authorization to work in the United States and are encouraged
to participate in CAPSBC’s direct deposit payroll program. In those instances where employees cannot
participate in the direct deposit program, they will have the opportunity to participate in a pay card program.
CAPSBC employment status is “at will” with or without benefits and employment can be terminated at any
time with or without cause. Employee works at the discretion of the Appointing Authority and is ineligible for
any disciplinary/grievance/layoff appeal rights.
DATE POSITION APPLIED FOR ______________________________________________________
GENERAL INFORMATION (Applications must be typed and not hand written. Applicants can go to the CAPSBC website
to complete an application, print it and submit the completed application to the Operations Division).
IMPORTANT: Applications are part of the hiring process and must be filled out completely in order to be accepted for
consideration. Insufficiently completed applications will be rejected.
_____________________________________________________________________________________________________
NAME: LAST FIRST MIDDLE INITIAL
_____________________________________________________________________________________________________
ADDRESS: NUMBER STREET CITY STATE ZIP CODE
______________________________________________________________________________________________________
PHONE NUMBER: HOME WORK MESSAGE
CAN YOU, AFTER OFFER OF EMPLOYMENT, SUBMIT VERIFICATION OF YOUR LEGAL RIGHT TO WORK IN THE UNITED
STATES? (IMMIGRATION AND NATURALIZATION SERVICE (INS) REGULATIONS REQUIRE ALL EMPLOYEES HIRED
AFTER 11/06/86 TO PROVIDE PROOF OF LEGAL STATUS TO BE EMPLOYED IN THE UNITED STATES). ____ YES ____
NO
IF NOT, DO YOU HAVE THE LEGAL RIGHT TO WORK IN THE UNITED STATES? YES NO
(DATE STAMP)
Rev 03/19
APPLICATION FOR EMPLOYMENT
Community Action Partnership
Of San Bernardino County
696 South Tippecanoe ♦ San Bernardino ♦ California 92408-2607
(909) 723-1531 ♦ www.capsbc.org
Page 2 of 7
EDUCATION: Check appropriate box if you possess one of the following:
[ ] High School Diploma [ ] G.E.D. Certificate [ ] California High School Proficiency Certificate
Circle Highest Grade Completed 1 2 3 4 5 6 7 8 9 10 11 12 College 1 2 3 4 Post Graduate Years
Name of High School
Address of High School
Certificate / Diploma
Name and Address of College, University,
Vocational School or Institute
Major/Minor
Units Completed
Semester/Quarter
A.
□YES
□NO
B.
□YES
□NO
C.
□YES
□NO
D.
□YES
□NO
Are you now, or have you previously been an employee of this agency? Yes No
If so, please indicate.
____________________________________________________________________________________
Do you have any relations by blood or marriage employed by the Community Action Partnership of San Bernardino
County? If Yes, give name(s) relation and departments.
_____________________________________________________________________________________________________
Have you been discharged from a position or terminated during a probationary period for unsatisfactory service, or
have you ever resigned upon request to avoid discharge? Give name and address of employer, date of discharge or
forced resignation and the reason below.
_____________________________________________________________________________________________________
DO YOU POSSESS A VALID CALIFORNIA DRIVER LICENSE? YES NO (Applicable only for those
positions requiring a California Driver License)
STATE: TYPE OF LICENSE: NO.: EXPIRATION DATE: _______________________
Are you currently employed? Yes No
If so, may we contact your employer? Yes No
WHAT MACHINES DO YOU PROFICIENTLY OPERATE? (office, commercial, equipment)
__________________________________________________________________________________________________
Special Skills: Typing wpm Internet ___
MS Word MS Excel MS PowerPoint ____ Windows 7 ____ Windows 10 ____
Other
Are you fluent in any language in addition to English? If so, please specify your skills. (Complete only when required on
job announcement).
Language Understand Speak Read Write
_______
Page 3 of 7
EMPLOYMENT HISTORY
EXPERIENCE: Provide a complete employment history beginning with your current or most recent job. In additional space is needed, attach a sheet
of paper. Do not refer to a resume. Only those jobs listed will be considered in determining your eligibility. List each job title separately, even if the
employer is the same. Incomplete information will result in disqualification.
RESUME MAY BE ATTACHED BUT WILL NOT BE ACCEPTABLE AS A SUBSTITUTE FOR COMPLETING THIS SECTION.
Name, Address & Telephone Number of Employer:
DATES EMPLOYED
JOB TITLE AND DESCRIPTION OF DUTIES
Month Year Month Year
From: / To: /
Total Months │ Hours Per Week
Name & Title of Immediate Supervisor
REASON FOR LEAVING
Name, Address & Telephone Number of Employer:
DATES EMPLOYED
JOB TITLE AND DESCRIPTION OF DUTIES
Month Year Month Year
From: / To: /
Total Months │ Hours Per Week
Name & Title of Immediate Supervisor
REASON FOR LEAVING
Name, Address & Telephone Number of Employer:
DATES EMPLOYED
JOB TITLE AND DESCRIPTION OF DUTIES
Month Year Month Year
From: / To: /
Total Months │ Hours Per Week
Name & Title of Immediate Supervisor
REASON FOR LEAVING
Name, Address & Telephone Number of Employer:
DATES EMPLOYED
JOB TITLE AND DESCRIPTION OF DUTIES
Month Year Month Year
From: / To: /
Total Months │ Hours Per Week
Name & Title of Immediate Supervisor
REASON FOR LEAVING
EMPLOYMENT HISTORY (CONT'D)
Page 4 of 7
Name, Address & Telephone Number of Employer:
DATES EMPLOYED
JOB TITLE AND DESCRIPTION OF DUTIES
Month Year Month Year
From: / To: /
Total Months │ Hours Per Week
Name & Title of Immediate Supervisor
REASON FOR LEAVING
Name, Address & Telephone Number of Employer:
DATES EMPLOYED
JOB TITLE AND DESCRIPTION OF DUTIES
Month Year Month Year
From: / To: /
Total Months │ Hours Per Week
Name & Title of Immediate Supervisor
REASON FOR LEAVING
Name, Address & Telephone Number of Employer:
DATES EMPLOYED
JOB TITLE AND DESCRIPTION OF DUTIES
Month Year Month Year
From: / To: /
Total Months │ Hours Per Week
Name & Title of Immediate Supervisor
REASON FOR LEAVING
Name, Address & Telephone Number of Employer:
DATES EMPLOYED
JOB TITLE AND DESCRIPTION OF DUTIES
Month Year Month Year
From: / To: /
Total Months │ Hours Per Week
Name & Title of Immediate Supervisor
REASON FOR LEAVING
Page 5 of 7
Would you object to the following:
Traveling as required by this position? ___Yes No ___
Working over regular working hours when required? ___ Yes ___No
Will you require any accommodation due to a disability while competing in the selection process?
Yes ___ No ___ If Yes, please describe.
REFERENCES:
List at least three references whom you have known for at least three years; do not include relatives.
NAME ADDRESS/PHONE NUMBER OCCUPATION
In case of Emergency, please contact:
NAME PHONE NUMBER ____________________
ADDRESS RELATIONSHIP ____________________
I HEREBY GIVE MY CONSENT TO HAVE CAPSBC OPERATIONS DIVISION VERIFY MY PAST
EMPLOYMENT.
SIGNATURE OF APPLICANT DATE_____________________
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Page 6 of 7
AN EQUAL EMPLOYMENT OPPORTUNITY AND ADA COMPLIANT EMPLOYER
CERTIFICATION OF SIGNATURE STATEMENT
I hereby certify that all statements on this application are true and complete. I further
agree that the information and materials submitted with the application become the
property of Community Action Partnership of San Bernardino County. In the event of
employment, I understand that false or misleading information given in my application
or interview(s) may be considered cause for immediate termination. I further agree that
the employer shall not be liable in any respect if my employment is terminated because
of falsity of statements, answers or omissions made by me. I also authorize the
companies, schools or persons named above to give any information relevant to
my bona fide employment qualifications and hereby release the aforementioned from
all liability for any damages for issuing this information. A copy of this
authorization will be considered to be as valid as the original.
Application will not be considered unless signed.
SIGNATURE OF APPLICANT DATE
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Page 7 of 7
Position Applied For: ___________________________________
Date: _________________________________________________
CAPSBC IS ASKING APPLICANTS TO COMPLETE THIS FORM IN ORDER
TO COMPLY WITH UNITED STATES GOVERNMENT EQUAL OPPORTUNITY Decline to complete [ ]
REQUIREMENTS. THIS INFORMATION IS SOLICITED ON A VOLUNTARY
BASIS AND HAS NO BEARING ON YOUR APPLICATION, ELIGIBILITY
OR SELECTION. INFORMATION THAT YOU PROVIDE WILL BE KEPT
CONFIDENTIAL AND WILL BE USED ONLY IN ACCORDANCE WITH
STATE AND FEDERAL REGULATIONS.
PLEASE COMPLETE:
ETHNIC IDENTIFICATION (See below for explanation) SEX
1. [ ] American Indian/Alaskan Native 1. [ ] Female
2. [ ] Asian/Pacific Islander 2. [ ] Male
3. [ ] Black
4. [ ] Filipino
5. [ ] Hispanic
6. [ ] White
DISABILITY (See below for explanation) AGE GROUP
Please check if appropriate: 1. [ ] Under 21
1. [ ] Hearing 2. [ ] 21-29
2. [ ] Visual 3. [ ] 30-39
3. [ ] Speech 4. [ ] 40-49
4. [ ] Physical 5. [ ] 50-59
5. [ ] Developmental 6. [ ] 50 or over
6. [ ] Other (Specify)
VETERAN STATUS SOURCE
Are you a Vietnam Era Veteran? How did you learn about this job opening?
1. [ ] Yes
2. [ ] No
DEFINITION
AMERICAN INDIAN OR ALASKAN NATIVE: All persons having origins in any
of the original peoples of North America, and who maintain cultural
identification through tribal identity.
ASIAN OR PACIFIC ISLANDER: All persons having origins in any of the
original peoples of the Far East, Southeast Asia, the Indian Subcontinent or
the Pacific Islands.
BLACK: All persons having origins in any of the Black racial groups of Africa,
not of Hispanic origin.
FILIPINO: All persons having origins in any of the Philippine Islands.
HISPANIC: All persons of Mexican, Puerto Rican, Central or Southern
American, or other Spanish culture or origin, regardless of race.
WHITE: All persons having origins in any of the original peoples of Europe,
North Africa, or the Middle East, not of Hispanic origin.
DISABILITY
VISUAL: Persons who are legally blind in one or both
eyes and whose visual acuity even after correction (eye
glasses or contact lenses) is 20/200 visual acuity or
restricted in the visual field to 20 degrees.
HEARING: Persons with total deafness or inability to hear a normal
conversation and/or use a telephone without the aid of an
assistive device.
SPEECH: Persons with speech impairments when
speech is unintelligible in normal conversations.
PHYSICAL: Persons with orthopedic impairments, amputations of
functional limitations if there is: (a) loss of significant
impairment of one or both major upper extremities; (b)
loss or significant impairment of one or both major lower
extremities; and (c) impairment of the trunk, back or
spine when there is a medically diagnosed disability
which substantially limits one or more major life
activities.
DEVELOPMENTAL: Persons who meet the legal definition or have been
identified as developmentally disabled. This includes
autism, cerebral palsy, epilepsy, mental retardation, and
other neurological impairments.
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Community Action Partnership of San Bernardino County (CAPSBC)

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Completed 27 April 2021

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