(rev 11/2016)CalHR 884
Page of
A. Applicant Information
Criminal Record Supplemental Questionnaire
California Department of Human Resources
State of California
B. Criminal Record Questionnaire
E-mail Adress
Applicant's Name (Last, First, M.I.) Easy ID
Mailing Address (Street Address / City / County / State / ZIP Code)
1. Have you ever been convicted by any court of a misdemeanor crime of domestic violence?
Applicant's Signature Date Signed
C. Certification (if not signed, your application may be rejected)
Work Telephone Number
Explanations
Exam Title(s) for which you are applying
I certify under penalty of perjury that the information I have entered on this application is true and complete to the
best of my knowledge. I further understand that any false, incomplete, or incorrect statements may result in my
disqualification from the examination process or dismissal from employment with the State of California. I
authorize all agencies to release any information they may have concerning the information provided on this
supplemental application to the State of California.
Home Telephone Number
2. Have you ever been convicted by any court of a felony?
Not all Examinations require this Criminal Record Supplemental Questionnaire. Please review the Examination
Bulletin to determine if the questionnaire is required before completing.
Yes No
Yes No
Month of
Birth
Day of
Birth
Last 4 digits of Social
Security Number
First 3 letters of
last name at birth
Applicant Identification Number (Easy ID)
Print Form
Reset Form
(rev 11/2016)CalHR 884
Page of
INSTRUCTIONS
Read the following instructions carefully before completing this Criminal Record Supplemental
Questionnaire. If the Examination Bulletin requires this Criminal Record Supplemental Questionnaire to
be submitted with your application, you must complete all sections and answer the required questions
completely and accurately.
Applicant Identification Number (Easy ID) – Enter the required tracking information on the Criminal
Record Supplemental Questionnaire: the first three letters of your last name at birth, the month and day
of your birth and the last four digits of your Social Security Number.
Easy ID – The Easy ID represents a compilation of the data collected from the Applicant Identification
Number section. If you are unable to determine your Easy ID, please leave it blank.
Exam for which you are applying – Fill in the title(s) of the examination for which you are applying as it
is listed on the Examination Bulletin.
Questions 1 & 2 – Answer these questions only if required on the Examination Bulletin.
Explanations – Use this section to explain the details of any response that requires additional
information. Be through and attach additional sheet(s) if necessary.
Signature – Your signature and the date signed is required. If the Criminal Record Supplemental
Questionnaire is not signed, it may be rejected.
California Department of Human Resources Privacy Notice on Information Collection
This notice is provided pursuant to the Information Practices Act of 1977.
The California Department of Human Resources (CalHR), Selections Division, is requesting the
information specified on this form pursuant to Government Code 18934 and the Privacy Act of 1974.
The information collected will be used for state civil service employment and will/may be disclosed to
other State Departments and third party vendors for business purposes only as required by law.
Individuals should not provide personal information that is not requested or required.
The submission of all information requested is mandatory unless otherwise noted. If you fail to provide
the information requested, CalHR will not be able to determine your eligibility for state civil service
employment and contact you as necessary.
Department Privacy Policy
The information collected by CalHR is subject to the limitations in the Information Practices Act of 1977
and state policy. For more information on how we care for your personal information, please read our
Privacy Policy at http://www.calhr.ca.gov/pages/privacy-policy.aspx
.
Access to Your Information
The CalHR Privacy Officer is responsible for maintaining collected records. You have a right to access
records containing your personal information we maintain. To request access, contact:
CalHR Privacy Officer
1515 S Street, 500N
Sacramento, CA 95811
916-324-0455
CalHRPrivacy@calhr.ca.gov
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome