Contact Information

Country
State / Province*
Address
City
Email*
Confirm Email*
Phone
Cell Phone
Social Security Number

Employment Questions

Position Applying For
Do you have a valid driver's license?
  • Yes
  • No
If yes, please provide Driver's License #
If you are not a U.S. Citizen, do you have the legal right to remain permanently in the U.S.?
  • Yes
  • No
  • Not Applicable
Are you employed now?
  • Yes
  • No
If so, may we contact your employer?
  • Yes
  • No
  • Not Applicable
Are you applying for Regular Full-Time Work?
  • Yes
  • No
Are you applying for Regular Part-Time Work?
  • Yes
  • No
Are you applying for Temp Work (e.g. summer or holiday work?)
  • Yes
  • No
What days and hours are you available for work?
Why are you applying for work at United Cerebral Palsy of the North Bay?
If hired, do you have a reliable means of transportation to and from work?
  • Yes
  • No
Are you at least 18 years of age?
  • Yes
  • No
Can you present evidence of your U.S. citizenship or proof of your legal right to live and work in this country?
  • Yes
  • No
  • Not Applicable
Are you able to perform the essential functions of the job for which you are applying either with or without reasonable accommodation?
  • Yes
  • No
Have you ever applied or worked for UCP of the North Bay before?
  • Yes
  • No
If yes, when?
Do you have any friends or relatives working for UCP of the North Bay?
  • Yes
  • No
If yes, state name(s) and relationship.
Are you related to anyone served by the Regional Center system?
  • Yes
  • No
Have you ever been investigated by Community Care licensing?
  • Yes
  • No
If you have answered yes to EITHER of these last two questions, please explain:
Have you ever been convicted of a criminal offense, felony or misdemeanor?
  • Yes
  • No
If yes, state below the nature of the crime (s), when and where convicted, and the disposition of the case. A criminal clearance is required by Community Care Licensing for any employee who has contact with our consumers. We will do a background check and Live Scan fingerprinting on all prospective employees. (Conviction of a criminal offense will not necessarily bar you from employment here. By law, your fingerprints must be submitted to the Federal Bureau of Investigation. If you disclose offenses on this application form, special consideration can be given to their nature and circumstances. Failure to make full disclosure will cause UCPNB to require your immediate termination of employment.)

Employment History

List all employment of the last five years, starting with the most recent.  Please complete the following section even if attaching a resume.

Employer #1

Name of Employer
Employer Address
Type of Business
Supervisor's Name
Supervisor's Phone Number
Your Position and Duties
Date of Employment (Start date - End date)
Hourly Wage (Starting and Ending)
Reason for Leaving
May we contact your employer?
  • Yes
  • No

Employer #2

 
Name of Employer
Employer Address
Type of Business
Supervisor's Name
Supervisor's Phone Number
Your Position and Duties
Date of Employment (Start date - End date)
Hourly Wage (Starting and Ending)
Reason for Leaving
May we contact your employer?
  • Yes
  • No

Employer #3

 
Name of Employer
Employer Address
Type of Business
Supervisor's Name
Supervisor's Phone Number
Your Position and Duties
Date of Employment (Start date - End date)
Hourly Wage (Starting and Ending)
Reason for Leaving
May we contact your employer?
  • Yes
  • No

Education

Name(s) of High School(s) Attended
Location(s) of High School(s) attended
Years Attended High School (include date of graduation)
Name of College(s) Attended
Years Attended College (include date of graduation)
Location(s) of College(s) attended
Trade School(s) Attended
Trade School(s) - years attended (include graduation or certification)

References

Give below the names of three persons not related to you whom you have known for a minimum of one year, and be sure to include phone numbers.

 
Reference #1 Name & Relationship
Reference #1 Phone
Reference #1 Address
Reference #2 Name & Relationship
Reference #2 Phone
Reference #2 Address
Reference #3 Name & Relationship
Reference #3 Phone
Reference #3 Address

Initials

1. I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of material facts on this application or on any document used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery.
  • Initialized
2. I hereby authorize investigation of all statements and records contained in this application and I authorize all references I have listed to disclose to UCPNB any and all information related to my work records without giving me prior notice of such disclosure. In addition, I hereby release the United Cerebral Palsy of the North Bay, my former employers and all other persons, corporations, partnerships and associations from any and all claims arising out of or in any way related to such investigation or disclosure.
  • Initialized
3. Further, I understand and agree that my employment is at-will and for no definite period and may be terminated at any time without any previous notice at the option of the United Cerebral Palsy of the North Bay or myself, and that no promises or representation contrary to the foregoing are binding on UCPNB unless made in writing and signed by me and the agency’s representative. I agree to abide by the rules of the United Cerebral Palsy of the North Bay set forth in the Personnel Policies and Staff Manual. I agree to submit an authenticated fingerprint card, evidence of good health, T.B. test result, and a D.M.V. Driving Record printout before reporting to work.
  • Initialized

Cover Letter & Resume

Click here to email and attach Cover Letter and Resume.

 
 
Additional Comments

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