STUDENT EMPLOYMENT APPLICATION
YUBA COMMUNITY COLLEGE DISTRICT
NAME: ___________________________________ DRIVER’S LICENSE #: _______________________________ DATE:___________________
STREET ADDRESS: _________________________________ CITY: ______________________ STATE: ____________ ZIP: ____________
AREA CODE: ___________ PHONE: ___________________ Do you qualify for a Federal Work Study Grant? Yes No
Do you qualify for a CalWORKs Work Study Grant: Yes No
Have you ever been convicted, pled guilty to or pled no contest to any criminal offense by any court? Yes No
If yes, please note the date and place of each offense, the specific charge, the date and place of conviction, or plea, the fine or sentence received or the diversion program entered.
You may omit any traffic offense for which the only punishment imposed was a fine of less than $100.
Any other offense for which you were convicted for which the punishment imposed was a fine in excess of $100, and required serving a jail or prison sentence, or
probation, MUST BE reported. (A criminal record is not necessarily a bar to employment. Each such case is given individual consideration, based on job related criteria.)
Position(s) applied for: _____________________________________________________________________________________________________________________________
Skills (Typing, Office Machines, Computer/Word Processing, Welding, Carpentry, etc.)
REFERENCES: Provide names and phone numbers of three people, not relatives, that we may contact who have knowledge of your job skills, experience and ability.
Name: ______________________________________________________________________________ Phone: _____________________________
Name: ______________________________________________________________________________ Phone: _____________________________
Name: ______________________________________________________________________________ Phone: _____________________________
CERTIFICATION: I hereby certify that all statements made on this application and any attachments are true and complete to the best of my knowledge. I understand that any
false, incomplete or incorrect statements may result in my disqualification from the examination process or dismissal from employment with Yuba Community College District
“the District”.
I authorize the District to investigate my references, work record, education, or any other matters relating to my suitability for employment. I authorize and direct my former or
current employers and education institutions to release to the District any information they may have concerning my employment or education. I also authorize the District to
obtain and review any documents or records, including driving records, which are applicable to my employment. I release the parties listed above from any and all liability related
to this process of supplying or gathering any information about my suitability for employment.
SIGNATURE OF APPLICANT: _______________________________________________ DATE: ___________________________________
WORK EXPERIENCE: List positions held starting with your most recent job. Include volunteer experience:
Date of Employment: ______________ Job Title: ______________________________________________________________________________
Employer Name and Address: ______________________________________________________________________________________________
Type of Work Performed:
Reason for Leaving: ______________________________________________________________________________________________________
Date of Employment: ______________ Job Title: ______________________________________________________________________________
Employer Name and Address: ______________________________________________________________________________________________
Type of Work Performed:
Reason for Leaving: ______________________________________________________________________________________________________
Date of Employment: ______________ Job Title: ______________________________________________________________________________
Employer Name and Address: ______________________________________________________________________________________________
Type of Work Performed:
Reason for Leaving: ______________________________________________________________________________________________________
Revised: 3/2006
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