CIRCLE HIGHEST YEAR COMPLETED DIPLOMA CURRENTLY ENROLLED IN HIGH SCHOOL COMPLETION COURSE?
6789101112
NO
YES IF YES, GIVE EXPECTED COMPLETION DATE
4. EDUCATION
DATES
FROM TO
NAME AND ADDRESS OF EMPLOYER
3. PREVIOUS EMPLOYMENT (List most recent experience first. If additional space is needed, please attach a separate page.)
STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
PERSONNEL RECORD
(Form to be completed by employee)
NAME (LAST FIRST MIDDLE)
TITLE SALARY HOURS DATE OF EMPLOYMENT
NAME OF SUPERVISOR
ADDRESS ARE YOU 18 YEARS OF AGE OR OLDER?
YES
NO IF NO, PLEASE STATE YOUR AGE
_____________________________
TELEPHONE
1. PERSONAL
2. POSITION
EMPLOYMENT — RELATED EDUCATION COURSES
TELEPHONE
NUMBER
JOB TITLE AND
TYPE OF WORK
NEAREST LIVING RELATIVE — NAME:
ADDRESS
TELEPHONE NUMBER
RELATIONSHIP
REASON FOR
LEAVING
COURSE TITLE
NAME OF SCHOOL OR ORGANIZATION
AND ADDRESS
NUMBER
UNITS
COMPLETED
DATE
COMPLETED
CURRENTLY
ENROLLED
(OVER)
LIC 501 (3/99)
DATE
NAME OF FACILITY
FACILITY ADDRESS
FACILITY FILE NUMBER
SOCIAL SECURITY NUMBER: (VOLUNTARY FOR ID ONLY)
DATE OF LAST PHYSICAL EXAMINATION DATE OF LAST TB TEST
HAVE YOU EVER BEEN EMPLOYED UNDER A DIFFERENT NAME?
YES
NO
IF YES, PLEASE LIST ALL NAMES USED.
DO YOU POSSESS A VALID CALIFORNIA DRIVER'S LICENSE?
YES
NO
CDL NUMBER
HAS YOUR DRIVER'S LICENSE EVER BEEN SUSPENDED OR REVOKED?
YES
NO
IF YES, PLEASE EXPLAIN ON BACK OF FORM.
