Fillable HR011910 HRLY (Cerritos College)

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HR011910 HRLY (Cerritos College)

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  • 49 check-boxes
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Country of origin: US
File type: PDF

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Temporary Short-Term Hourly Application
It is necessary to complete this application in full, whether or not a resume is attached.
NAME
Last Name:
First Name:
M.I.
Address:
State & Zip Code:
Home phone:
Business or
message phone:
E-mail address:
EDUCATION
LEVEL/SCHOOL NAME
CITY/STATE
DEGREE
MAJOR
GRADUATED
High School
Name:
Yes No
College/University
Name:
Yes No
Other
Name:
Yes No
GENERAL INFORMATION
Have you ever been employed by Cerritos College?
Yes No If yes, when?
Do you have the legal right to work in the United States?
Yes No
Do you have relatives, by blood or law, who are currently employed by Cerritos College?
Yes No If yes, provide name and department:
Have you ever been arrested for any crime (other than a minor traffic violation) which resulted in a conviction or a plea of nolo contender?
Yes No If yes, contact Human Resources and request the Record of Conviction form.
A conviction will not necessarily disqualify an applicant from employment.
REFERENCES: In addition to current or former supervisor, you may list additional work references. Do not include relatives.
NAME
COMPANY
PHONE # OR EMAIL
HIRING SUPERVISOR USE ONLY
REFERENCES CHECKED BY (Name)
FOR DEPARTMENT USE ONLY
Job Class Code
Classification
Short-Term
Substitute
Are you a current Cerritos College student carrying 12 units
12 units or more? Yes No
Cerritos College
11110 Alondra Blvd.
Norwalk, CA 90650
(562) 860-2451
www.cerritos.edu
EMPLOYMENT HISTORY (starting with current or most recent employer)
(1) Company:
Starting position:
Salary:
From:
Department:
Last position:
Salary:
To:
Job duties:
Person to
contact:
Address:
Phone:
May we contact this company for employment references? Yes No Type of employment: Full-time Part-time Temporary
(2) Company:
Starting position:
Salary:
From:
Department:
Last position:
Salary:
To:
Job duties:
Person to
contact:
Address:
Phone:
May we contact this company for employment references? Yes No Type of employment: Full-time Part-time Temporary
I certify that the information I have provided in applying for this job is true and complete to the best of my knowledge and belief. I give Cerritos College
and its authorized agents permission to verify and/or disclose any information given in connection with this application for personnel/employment
purposes. I acknowledge that any misstatement or omission in the application materials may be cause for elimination from further consideration or
dismissal if hired. I hereby authorize any and all persons and agencies to furnish to Cerritos College any information, including documents in my
personnel file, which may be necessary to verify this application and any other materials submitted, and hereby waive any rights of privacy to the
information or documents which I may have under any federal, state, or local law, ordinance or rule. I also understand that an incomplete application
packet may delay or prevent opportunities with Cerritos College.
Applicant’s Signature:
________________________________________________________ Date: __________________________________________________
Cerritos College is an Equal Opportunity Employer with a commitment to provide equal opportunity for all without regard to race, religion, national origin, sex, age, handicap, medical
condition or Vietnam era veteran status. Cerritos College complies with Title IX Educational Amendment of 1962 prohibiting sex discrimination in education. If you have a disability, and
require accommodation to complete this application, contact the Human Resources office. Cerritos College employs only individuals lawfully authorized to work in the United States. Cerritos
College does not provide sponsorship for changes in immigration status for the purpose of employment in the United States.
HR011910-HRLY
6
Cerritos College
11110 Alondra Blvd.
Norwalk, CA 90650-6298
(562) 860-2451
www.cerritos.edu
Record of Conviction
Supplemental Employment Application Information
Submit with Application only if Necessary
Because of our responsibility to students and to the public, it is important to be extremely careful in screening applicants with conviction
records. You may be disqualified from consideration for, or dismissed from employment with Cerritos College unless you fill out this form
accurately and completely. In accordance with District policies, procedures, and the provisions of the Education Code, all prospective
employees are fingerprinted and the fingerprints are submitted for verification.
In completing this form, you must include all sex offenses and controlled substance offenses even if they have been set aside by Penal
Code section 1203.4, but you may omit minor traffic infractions. A criminal record will not automatically disqualify you from your
employment, but failure to list all convictions may result in disqualification or dismissal.
INSTRUCTIONS: In the space below, give complete details for every time you have pled guilty, been convicted, fined, imprisoned, placed
on probation, or given a suspended sentence in court. Please indicate if the situation was a misdemeanor or felony offense. If you are in
doubt, list the conviction and explain. Do not include minor traffic infractions where the fine was $300 or less. For additional space, use a
separate sheet.
Offense
(Brief Description)
Offense
Code No.
(if known)
Date
Mo/Yr
Location
(City & State)
Disposition (imprisonment, fine,
probation, suspended sentence)
Misd*
Flny*
* Misd = Misdemeanor Flny = Felony
Are you currently out on bail or released on your own recognizance pending
trial regarding a criminal matter?
No Yes (please complete information below)
INSTRUCTIONS: In the space below, give complete details regarding the criminal matter(s) for which you are currently out on bail or
released on your own recognizance. For additional space, use a separate sheet.
Offense
(Brief Description)
Offense
Code No.
(if known)
Date
Mo/Yr
Location
(City & State)
Disposition (imprisonment, fine,
probation, suspended sentence)
Misd*
Flny*
* Misd = Misdemeanor Flny = Felony
DECLARATION: I declare under penalty of perjury under the laws of the State of California that the information listed above is true and
complete.
Applicant’s Signature: _____________________________________________________________ Date: _______________________________________
 PLEASE NOTE 
IF YOU ANSWERED YES TO THE QUESTION: Have you ever been
convicted of a criminal offense? complete and submit this form
with your application package, OTHERWISE, DO NOT SUBMIT IT
.
Last Name
First Name Middle Position applied for:
8
Cerritos College
11110 Alondra Blvd.
Norwalk, CA 90650-6298
(562) 860-2451
www.cerritos.edu
Discharge Statement
Supplemental Employment Application Information
Submit with Application only if Necessary
Last Name First Name Middle
Position applied for:
Have you ever been discharged or resigned to avoid discharge from any position?
Yes No
Discharge from employment or forced resignation will not automatically disqualify you from employment, but failure to list
all discharges or forced resignations may result in disqualification or dismissal from employment.
INSTRUCTIONS: In the space below, give complete details for every time you were discharged or forced to resign from
any position.
DECLARATION:
I declare under penalty of perjury under the laws of the State of California that the information listed above is true and
complete.
Applicant’s Signature: _____________________________________________________________ Date: ________________________
 PLEASE NOTE 
IF YOU ANSWERED YES TO THE QUESTION: Have you ever
been discharged or forced to resign from any position?
complete and submit this form with your application
package, OTHERWISE, DO NOT SUBMIT IT
.
click to sign
signature
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4
Cer Cerritos College
11110 Alondra Blvd.
Norwalk, CA 90650-6298
(562) 860-2451
www.cerritos.edu
Applicant Diversity Survey (Optional)
Supplemental Equal Employment Opportunity Application Information
Federal and State mandates require our institution to compile data on the sex, age, ethnicity, disability, and
veteran status of applicants for employment opportunities. To assist us in complying with this requirement, we
are requesting that you complete and return this form. This information will be used to evaluate the
effectiveness of our recruitment efforts. It should be emphasized that it is the policy of the Cerritos Community
College District to hire solely on the basis of the applicant’s qualifications in relation to the requirements and
selection criteria for the particular position. Information obtained from the applicant on this survey is not
provided to the selection committee responsible for making employment recommendations.
It should be understood that you have the option of providing or not providing the information requested, and
that your decision in this matter will not affect the status of your application. Your cooperation in completing
the survey is appreciated.
Last Name
First name
Middle
Position applied for:
GENDER: Male
Female
AGE: 40 years or over
Below 40 years
VIETNAM ERA VETERAN (August 4, 1964 - May 5, 1975)
No Yes
ETHNIC GROUP (with which you most closely identify):
American Indian or Alaskan Native
Asian or Pacific Islander
Japanese
Guamanian
Asian Indian
African American/Black
Chinese
Samoan
Filipino
Korean
Laotian
Hawaiian
Caucasian/White
Vietnamese
Cambodian
Asian Other
Pacific Islander Other
Hispanic/Latino
Mexican, Mexican-American, Chicano
Mixed Ethnic (Please specify the ethnic groups)
Central American
South American
Hispanic Other
DISABILITIES - Physical or mental impairment that limits one or more major life activities; has a record of such an
impairment; or is regarded as having such an impairment.
Applicant’s Signature: ________________________________________________________ Date:
None Yes, please identify:
How did you hear about this
vacancy?
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HR011910 HRLY (Cerritos College)

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Completed 20 July 2020

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