Personnel Record LIC 501 - CDSS Public Site

1 CIRCLE HIGHEST YEAR COMPLETEDDIPLOMACURRENTLY ENROLLED IN HIGH SCHOOL COMPLETION COURSE?6789101112 NO YESIF YES, GIVE EXPECTED COMPLETION TONAME AND ADDRESS OF EMPLOYMENT(List most recent experience first. If additional space is needed, please attach a separate page.)STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCYCALIFORNIA DEPARTMENT OF SOCIAL SERVICESPERSONNEL Record (Form to be completed by employee)NAME (LASTFIRSTMIDDLE)TITLESALARYHOURSDATE OF EMPLOYMENTNAME OF SUPERVISORADDRESSARE YOU 18 YEARS OF AGE OR OLDER? YES NOIF NO, PLEASE STATE YOUR AGE_____TELEPHONE() RELATED EDUCATION COURSESTELEPHONENUMBERJOB TITLE AND TYPE OF WORKNEAREST LIVING RELATIVE NAME:ADDRESSTELEPHONE NUMBERRELATIONSHIPREASON FORLEAVINGCOURSE TITLENAME OF SCHOOL OR ORGANIZATIONAND ADDRESSNUMBERUNITSCOMPLETEDDATECOMPLETED CURRENTLYENROLLED(OVER)LIC 501 (3/99)DATENAME OF FACILITYFACILITY ADDRESSFACILITY FILE NUMBERSOCIAL SECURITY NUMBER: (VOLUNTARY FOR ID ONLY)- -DATE OF LAST PHYSICAL EXAMINATIONDATE OF LAST TB TESTHAVE YOU EVER BEEN EMPLOYED UNDER A DIFFERENT NAME?

2 YES NO IF YES, PLEASE LIST ALL NAMES YOU POSSESS A VALID CALIFORNIA DRIVER'S LICENSE? YES NOCDL NUMBERHAS YOUR DRIVER'S LICENSE EVER BEEN SUSPENDED OR REVOKED? YES NOIF YES, PLEASE EXPLAIN ON BACK OF hereby certify under penalty of perjury that the above statements are true and correct. I give my permission for any necessary names of three persons who can give information about your background, character, abilities, TO YOU(FRIEND, EMPLOYER, ETC.) (Continued) AND TECHNICAL QUALIFICATIONSNO. OFYEARSCOMPLETEDNO. OFUNITSCOMPLETEDDIPLOMADEGREE ORCERTIFICATENAME UNIVERSITY, COLLEGE OR BUSINESS SCHOOLAND ADDRESSMAJORSUBJECTDATECOMPLETEDA. List Licenses or Certificates of Competence held:B. Names of Professional Associations of which you are a member:NOTES:SIGNATURE OF EMPLOYEEDATE