Inland
Behavioral and Health Services, Inc.
1963 North ‘E’ Street
San Bernardino, CA 92405
Ph: (909) 881-6146 Fx: (909) 881-0111
Email: personnel@ibhealth.org
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Referral Source:
Advertisement
Employment Agency
Friend
Walk-In
Relative
Other:
PERSONAL INFORMATION
Last Name:
First
Middle Initial
Date
Street Address:
City:
State:
Zip:
Home Telephone:
Business Telephone :
Social Security #
When will you be available to begin work?
Pay Expected
Position applying for:
I’m available to work:
Full-time
Part-Time
Temporary
Have you ever been employed with us?
No
Yes
Have you ever applied for employment with
us?
No
Yes
If “Yes”, when? Month/Year
Location:
Can you travel, if it is required for the
position?
No
Yes
Are you on a lay-off and subject to recall?
No
Yes
Will you work overtime if asked?
No
Yes
If employed and you are under the age of 18, can you furnish
a work permit?
No
Yes
Are you legally eligible for employment
in the United States?
No
Yes
Have you ever been bonded?
No
Yes
If “Yes”, with what employers?
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I. Required Information:
(please check the appropriate box for each question)
All positions require fingerprinting to conduct a criminal
background check. The fingerprints will be used to obtain
records of any criminal history you may have. A conviction
will not necessarily disqualify you from consideration for
employment. IBHS may consider the nature, date and circumstance
of the offense as well as whether the offense is relevant
to the duties of the position for which you have applied.
A conviction is any plea of guilty or nolo contendere (no
contest) or a verdict of guilty.
1. Have you ever been convicted of a felony or misdemeanor
offense by any court in California?
No
Yes
You may omit:
a. Traffic violations for which the fine imposed was $300.00
or less;
b. Any conviction specified in the Health & Safety code
section 11361.5 which pertains to various marijuana offenses;
c. Any conviction that has been sealed, expunged or legally
eradicated;
d. Any offense which was finally settled in juvenile court
or referred to the youth authority;
e. Any misdemeanor conviction for which probation has been
successfully completed or otherwise discharged AND the case
has been judicially dismissed pursuant to Penal Code section
1203.4, and individual must have taken an affirmative action
to file a petition with a court to have the conviction set
aside and been successful in that action.
2. Have you ever been convicted of a felony or misdemeanor
offense in another state?
No
Yes
(Criminal convictions in another state may be considered
in the evaluation of your application.)
3. Have you ever been arrested for an offense for which
registration as a sex offender may be required?
No
Yes
4. Have you ever been arrested for unlawful possession of
narcotics?
No
Yes
You may omit:
a. Cases for which diversion has been successfully completed;
and
b. Marijuana related convictions under California Health
and Safety Code Sections 11357(b) and/or (c), 11360(c),
11364, 11365 and 11550 that are more than 2 years old.
If you answered “yes” to question #1 - #4 please
describe in detail.
II. I hereby waive my right to receive
a copy of any public record obtained by IBHS pursuant to
California Civil Code Section 1786.53.
No
Yes
III. I authorize investigation of
all statements contained in this application.
No
Yes
Please give an accurate, complete full-time and part-time
employment record. Start with your present or most recent
employer. Include military service assignments and volunteer
activities. You may exclude organization names which indicate
race, color, religion, gender, national origin, handicap,
or other protected status. If you need additional space,
please continue on a separate sheet.
EMPLOYMENT EXPERIENCE
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Company Name:
Telephone:
Address:
Employment Dates (State month & year)
Start:
Last:
Name of Supervisor:
Weekly Pay:
Start:
Last:
Job Title:
Reason for Leaving:
Describe Your Work:
Is it ok to contact this employer?
No
Yes
If no, why?
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Company Name:
Telephone:
Address:
Employment Dates (State month & year)
Start:
Last:
Name of Supervisor:
Weekly Pay:
Start:
Last:
Job Title:
Reason for Leaving:
Describe Your Work:
Is it ok to contact this employer?
No
Yes
If no, why?
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Company Name:
Telephone:
Address:
Employment Dates (State month & year)
Start:
Last:
Name of Supervisor:
Weekly Pay:
Start:
Last:
Job Title:
Reason for Leaving:
Describe Your Work:
Is it ok to contact this employer?
No
Yes
If no, why?
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Prospective employees will receive consideration
without discrimination based on race, creed, color, sex,
age, national origin, handicap, veteran status or any condition
prescribed by state or local law.
EDUCATION
REFERENCES
Please provide 3 personal references who are not related
to you and are not previous employers.
Last Name:
First:
Telephone:
Address:
Years Acquainted:
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Last Name:
First:
Telephone:
Address:
Years Acquainted:
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Last Name:
First:
Telephone:
Address:
Years Acquainted:
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ADDITIONAL
INFORMATION
Membership in professional and civic organizations, special
announcements, awards, etc.
(Exclude those which may disclose your race, color, religion,
age or national origin)
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Special
Employment Notice to Disabled Veterans, Vietnam Ere Veterans,
and Individuals With Physical or Mental Handicaps.
Government
contractors are subject to 38 USC 2012 of the Viet Era Veterans
Readjustment Act of 1974 which requires that they take affirmative
action to employ and advance in employment qualified disabled
veterans of the Vietnam Era, and Section 503 of the rehabilitation
Act of 1973, as amended, which requires government contractors
to take affirmative action to employ and advance in employment
qualified handicapped individuals.
If
you are a disabled veteran, or have a physical or mental
handicap you are invited to volunteer this information which
will be treated as confidential. Failure to provide this
information will not jeopardize or adversely effect your
consideration for employment.
If
you wish to be identified, please sign below.
Handicapped Individual
Disabled Veteran
Vietnam Era Veteran
Signature:
Date:
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APPLICATION’S SIGNATURE
Please
read and understand this statement before signing you application:
The
information I have provided in this Application for Employment
is true, correct and complete. False, incomplete or misrepresented
information of any kind will be sufficient cause for my
application to be rejected or, if discovered after I am
employed, cause for immediate termination of my employment.
I
authorize the employer to contact and obtain information
about me from previous employers, educational institutions
and “references” I provided, and any other party
necessary to verify the accuracy of information I disclosed
in this application, a related employment resume or a personal
interview. To assist in the procession of my Application,
I waive all rights and claims I may otherwise have against
the employer or its representatives, for seeking, and using
information to evaluate my employment request and all other
persons, corporations or organizations who provide information
for this purpose.
This
application will expire in 30 days. After that date, unless
otherwise notified, I understand that my status as an applicant
will end. I may re-apply for employment in the future by
completing a new application.
This
application is not an employment agreement. If I accept
an offer of employment I understand the employer may terminate
my employment at any time, with or without cause and without
prior notice, unless required by law. I understand that
no one, other than an executive officer of the employer,
has authority to enter into any employment agreement with
terms contrary to the foregoing and then only in writing
signed by such officer.
I fully understand and accept all terms and conditions in
the above statement.
Signature:
Date:
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APPLICANT
IDENTIFICATION RECORD
Regulations of the California Fair Employment and Housing
Commission require employers to obtain certain information
from each job applicant. This form is used to provide each
applicant with the opportunity to provide such information
voluntarily. All information that is provided voluntarily
will be used only for record-keeping purposes. Further,
such information will be kept separate from application
and an employee’s main personnel file. Such information
will not be used for any discriminatory purposes.
1.
Sex:
Female
Male
2.
Position Applied For:
3.
Please Check One:
Alaskan Native
American Indian
Asian
Black
Caucasian
Hispanic
Pacific Islander
Other (self-described):
4.
National Origin:
Date:
ATTENTION
EMPLOYEE CANDIDATES
No
job offer is final until presented in an offer letter signed
by the CEO.
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