An Equal Opportunity
Affirmative Action Employer

EMPLOYMENT APPLICATION

providing equal employment opportunity
to all regardless of race, ancestry, color,
religion, age, sex, disability, medical
condition, marital or veteran status, place
of national origin and other categories
protected by law.
A resume may accompany your completed application form but do not submit a resume in place of completing any part of this
application.

PLEASE PRINT
Submit Form

Date: ______________

Applicant Information

Name: __________________________________________________________________
Address:________________________________________________________________
City/State: _________________________________ Zip Code_____________________
Home Telephone:
Business Telephone: _________________
Social Security Number: ___________________________________________________
Do you have a valid driver's license?
Yes No
State/License #: ___________________________Expiration Date: _________________
Have you ever applied to, or worked for CAPMC before?
Yes
No
If yes, when? ____________________________________________________________
Do you have any friends or relatives working for CAPMC?
Yes
No
If yes, state name and relationship: ___________________________________________
Are you a current/former Head Start Parent or Agency Volunteer?
Yes
Are you at least 18 years old?

Yes

No

No

Veterans, check here if you’re applying for Veteran’s Preference Points;
Please attach Form
DD214 to application
Are you able to perform the essential functions of the job for which you are applying, either with or
Yes
No
without reasonable accommodation?
(Note: We comply with ADA and consider reasonable accommodation measures that may be necessary
for eligible applicants/employees to perform essential functions.)
Have you ever been convicted of a criminal offense (felony or serious misdemeanor)? or involved in a
pending charge? (Conviction for marijuana-related offenses that are more than two years old need not be
listed.)
Yes
No
If yes, state nature of the crime(s), when and where convicted and disposition of the case:
________________________________________________________________________
(Note: No applicant will be denied employment solely on the grounds of conviction of a criminal offense.
The nature of the offense, date of the offense, the surrounding circumstances and the relevance of the
offense to the position(s) applied for may, however, be considered.)
Rev. 01/11

General Information

Each position requires an application
Position you are applying for: _____________________________________________________
Are you currently employed?
 Yes
If yes, may we contact your current employer?

 No
 Yes

Indicate the type of appointment(s) you will accept:
 Full-time position
 Part-time position

 Yes

Computer/Software Experience?
Typing Speed_____________
10-Key Touch____________

 No
 Temporary position
 Seasonal position

 No (Describe) __________________________

Education, Training and Experience
School

No. of years
Completed

Name and Address

Did you
graduate?

High
School

 Yes
 No

College/
University

 Yes
 No

Vocational/
Business

 Yes
 No

Degree or
Diploma

Special Skills
Do you speak, write or read any foreign languages?
 Yes
 No
If yes, which language(s)?
Do you have any other experience, training, qualifications, or skills which you feel make you especially
suited for this position?
 Yes
 No If yes, explain in detail below:

If this position requires a specific license or certificate, please complete:
Certificate of Training

License #

Date Issued

Date Expires

Rev. 01/11

Employment History
List all previous employers starting with your present or most recent position below.
Name of Company:
Name of Supervisor:
Address:
Street
City
State
Zip Code
Telephone Number: (
)
Position and Duties:
Dates of Employment:
To
Starting Rate of Pay: _________________________Ending rate of pay:
Reason for Leaving:
--------------------------------------------------------------------------------------------------------------------Name of Company:
Name of Supervisor:
Address:
Street
City
State
Zip Code
Telephone Number: (
)
Position and Duties:
Dates of Employment:
To
Starting Rate of Pay: _________________________Ending rate of pay:
Reason for Leaving:
--------------------------------------------------------------------------------------------------------------------Name of Company:
Name of Supervisor:
Address:
Street
City
State
Zip Code
Telephone Number: (
)
Position and Duties:
Dates of Employment:
To
Starting Rate of Pay: _________________________Ending rate of pay:
Reason for Leaving:
--------------------------------------------------------------------------------------------------------------------Name of Company:
Name of Supervisor:
Address:
Street
City
State
Zip Code
Telephone Number: (
)
Position and Duties:
Dates of Employment:
To
Starting Rate of Pay: _________________________Ending rate of pay:
Reason for Leaving:

Rev. 01/11

Criminal Record Statement

State law requires that persons associated with licensed facilities be fingerprinted and disclose any
conviction. A conviction is any plea of guilty or no contest or a verdict of guilty. The fingerprints will be
used to obtain a copy of any criminal history you may have.
Please answer the questions below even if:
 It happened a long time ago;
 It was only a misdemeanor;
 You  didn’t  have  to  go  to  court  (your  attorney  went  for you);
 You had no jail time or the sentence was only a fine or probation;
 You received a certificate of rehabilitation;
 The conviction was later dismissed, set aside or the sentence was suspended.
Have you ever been convicted of a crime in California?

 Yes

 No

Have you ever been convicted of a crime from another state, federal court, military or jurisdiction outside
of U.S.?
 Yes
 No
If you answered Yes, provide details below of the nature and circumstances of each crime and the date
and the location in which each crime occurred:
What was the offense?

In which state and city did you commit the offense?

When did this occur?

Tell us what happened?

Rev. 01/11

Please Read Carefully, Initial Each Paragraph and Sign Below (if there is any part of this page you
do not understand, please contact the Human Resources Office about it before signing).
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 on this application or on any documents 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.
I hereby authorize CAPMC to thoroughly investigate my references, work records, education and other
matters related to my suitability for employment and, further, authorize my current and former employers to
disclose to the company any and all letters, reports and other information pertaining to my employment with
them, without giving me prior notice of such disclosure. In addition, I hereby release CAPMC, my current
and former employers, and all other persons, corporations, partnerships and associations from any and all
claims, demands or liabilities arising out of or in any way related to such investigation or disclosure.
I understand that if offered employment, the offer is contingent upon my passing a pre-employment alcohol
and drug screen, fingerprint clearance(if applicable) and reference checks. Approval by the Parent Policy
Council/Committee, pre-employment physical and TB test is required for Head Start positions. By
signing this application, I voluntarily agree to submit to a pre-employment alcohol/drug screen and preemployment physical upon receipt of a verbal offer of employment. I understand that failure to pass the
alcohol/drug screen and/or physical will result in withdrawal of the employment offer.
I understand that nothing contained in the application or conveyed to me during any interview which may be
granted is intended to create an employment contract, implied or explicit, between me and CAPMC. In
addition, I understand and agree that if I am employed, during my first 12 months of employment; my
employment relationship with CAPMC is strictly voluntary and at our mutual will. I understand that if
employed, during my first 12 months, my employment may be terminated at any time, with or without prior
notice, with or without cause or reason, at the option of either myself or CAPMC, and that no promises or
representations contrary to the foregoing are binding on CAPMC unless made in writing and signed jointly
by the Executive Director and myself.
I understand and agree that any future changes in my title, duties, compensation, working conditions, and/or
CAPMC benefits, policies and procedures will not alter our at-will agreements.
I understand that if offered employment, I will, as a condition of employment, be required to submit proof of
my identity and legal right to work in the United States on my first day of employment.

If the position applied for requires driving in the course of work, I understand that I will be required to
possess a current and valid California driver's license and understand that I will be required to provide a copy
of my official driving record and proof of insurance. I also understand that any offer of employment is
contingent on my ability to be covered by CAPMC auto insurance, if required for my position.
Transportation Safety Sensitive Employees Only: If hired, I also agree to submit to random alcohol or
drug testing as a condition of employment. I agree that CAPMC may conduct alcohol or drug screening at its
sole discretion with or without notice, with or without cause or reason. I also understand that refusal to
submit to a random alcohol/drug screen will be considered a voluntary resignation of employment.
My signature below certifies that I have read and understand this complete page, and agree to the terms and conditions outlined
in this document.
____________________________________________________
Applicant’s Signature

_______________________________
Date

Rev. 01/11

* * Voluntary Information * *
An Equal Opportunity-Affirmative Action Employer
Human Resources Office – 1225 Gill Ave. – Madera, CA 93637
To help us carry out our EEO/AA obligations, please indicate if any of the following definitions apply to you.
VIETNAM ERA VETERAN. A person who (1) served on active duty for a period of more than 180 days and part of
which occurred between 8/5/64 and 5/7/75, and discharged or released there from with other than a dishonorable
discharge, or (2) was discharged or released from active duty for service-connected disability if any part of such active
duty was performed between 8/5/64 and 5/7/75.
DISABLED VETERAN. A person entitled to disability compensation under laws administered by the Veteran’s
Administration for disability rated at 30 percent or more or a person whose discharge or release from active duty was for
a disability incurred or aggravated in the line of duty.
DISABLED INDIVIDUAL. A person who (1) has a physical or mental impairment which substantially limits one or
more of such person’s major life activities, (2) has a record of such impairment or (3) is regarded as having such
impairment. We wish to accommodate otherwise qualified disabled applicants.
If you require special testing arrangements, please contact the Human Resources Office prior to test date so we can
accommodate you.
Please help us comply with the State and Federal law by completing this section. While you are not required to complete this
section, you should know that if you leave it blank we have the right to enter data for this purpose based upon our visual
assessment. To demonstrate that we meet equal employment opportunity requirements, periodically we must report statistical
information about applicants and employees to the California and United States governments. This information will be kept
separate and confidential and will not be used in any unlawful way to make any employment decision. The Community
Action Partnership of Madera County is an Affirmative Action Employer.
Age
under 21
Gender
Male

21-39

40-69

70 and over

Female

Please answer below based upon how you are known in your community.
Check Appropriate Box

Ƒ American Indian /Alaska Native:
A person having origins in any of the
original peoples of North and South
America (including Central America),
and who maintain tribal affiliation or
community recognition

Ƒ Asian:

A person having origins in any
of the original people of the Far East,
southeast Asian, or the Indian
Subcontinent, including, for example,
Cambodia, China, India, Japan, Korea,
Malaysia, Pakistan, the Philippine
Islands, Thailand, and Vietnam

Ƒ Black / African American:

A person
having origins in any of the black racial
group of Africa.

Ƒ Native Hawaiian / Other Pacific

Ƒ Hispanic / Latino:

Ƒ White:

A person of
Cuban, Mexican, Puerto Rican, South
or Central American, or other Spanish
culture or origin regardless of race

Islander: A person having origins in
any of the peoples of Hawaii, Guam,
Samoa, or other Pacific Islands

A person having origins in
any of the original peoples of Europe,
the Middle East, or North Africa

Ƒ Two or More Races:

All persons
who identify with more than one of
the above five races

I first learned of this job opening through: (Check One)

Ƒ CAPMC Job Bulletin / Website
Ƒ Newspaper __________________________
Ƒ Friend or relatives ____________________
Ƒ Organization or Group _________________

Ƒ School Placement Office
Ƒ Trade or Professional Publication ______________________
Ƒ Current CAPMC employee ___________________________
Ƒ Other ____________________________________________
Submit Form

Rev. 01/11