Print Form

A Not for Profit, 501C(3) Organization

COMMUNITY CATALYSTS
OF CALIFORNIA
Empowering Consumers, Enhancing Lives

An EquAl opportunity EmployEr pAgE 1

EmploymEnt ApplicAtion

Be specific. If a question does not apply to you, write “NA” (not applicable.) If a question requires additional data, attach sheets as necessary. Be sure you have read the job description for the position for which you have applied prior to completing this application. Please Print

1/6/2009 social security#: 615-44-3531 _____________________________ Date: ____________________________________ Polk, Angelica name (last, First Mi): ______________________________________________________________________ address: 8278 Grandstaff Drive Sacramento, Ca 95823 ________________________________________________________________________________
Permanent address if different from present address: ______________________________________________ ________________________________________________________________________________________ Home Phone #: 916-956-2449 ______________________________ Message Phone: ___________________________ EMPLOYMENT DESIRED:

direct service aide For which job/position are you applying?: ______________________________________________________
regular full-time work regular part-time work temporary work (i.e. summer, internship)

What days are you available for work? M-Sun ________________________________________________________ What hours are you available for work? Afternoons and some mornings _______________________________________________________ if applying for temporary work, during what period of time will you be available? _________________________ are you available for work on weekends? Yes no Yes no Would you be available to work over time, if necessary?

if hired, on what date can you start work? 1/07/2008 ______________________________________________________ PERSONAL INFORMATION: Have you ever applied to or worked for Community Catalysts of California before? Do you have friends or relatives working for Community Catalysts of California? Yes Yes no no

If yes, when and which office? ___________________________________________________

if yes, state name(s) and relationship: _____________________________________________ I am applying so that I can put my care Why are you applying for work at Community Catalysts of California? _________________________________
giver skills to good use. ________________________________________________________________________________________

if hired, would you have a reliable means of transportation to and from work?

Yes

no

09/08

A Not for Profit, 501C(3) Organization

COMMUNITY CATALYSTS
OF CALIFORNIA
Empowering Consumers, Enhancing Lives

An EquAl opportunity EmployEr

EmploymEnt ApplicAtion
pAgE 2

are you 18 years of age or older?

Yes

no

(if under 18, hire is subject to verification that you are of minimum legal age)

if hired, can you present proof of your legal right to work in the United states? Yes no are you able to perform the essential function of the job for which you are applying? Yes no if no, describe the functions that cannot be performed: ________________________________
(note: We comply with the aDa and consider reasonable accommodation measures that may be necessary for eligible applicant/ employees to perform essential functions.)

Have you ever been convicted of a felony? Yes no if yes, state the 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, the date of the offense, the surrounding circumstances and the relevance of the offense to the position(s) applied for may, however, be considered.)

are you currently employed? Yes no if yes, may we contact your current employer? EDUCATION, TRAINING AND EXPERIENCE

Yes

no

Do you speak a language other than english? Yes no if yes, which language(s)? Spanish ______________________________________________________ Do you have prior experience with social service/health care? Yes no if yes, please explain: My training that I received working as a training care giver student. ________________________________________________________________ Do you have any other experience, training qualifications or skills that you feel make you especially suited for Experience working with a diverse variety of work at Community Catalysts of California? if so, please explain: ____________________________________ people, cpr training, socialization skills, past volunteer work in a senior care home ________________________________________________________________________________________ are you a high school graduate or equivalent? Yes no

education: list all applicable educational experience, number of units, courses or degrees obtained. if you need additional space, continue on the back or on a separate sheet. SChOOL COLLEGE OThER OThER MAjOR OR COURSE CREDENTIALS CERTIFICATION/ DEGREE cna certification highschool diploma

Consumnes River College Valley Highschool

Criminal Justice general

09/08

A Not for Profit, 501C(3) Organization

COMMUNITY CATALYSTS
OF CALIFORNIA
Empowering Consumers, Enhancing Lives

An EquAl opportunity EmployEr

EmploymEnt ApplicAtion
pAgE 3

EMPLOYMENT hISTORY List all present and past work experience starting with your most recent employer (Last 10 years is sufficient.) account for all time, including schooling, relevant military service and periods of unemployment. if you need additional space, continue on the back or on a separate sheet. You must complete this section even if attaching a resume. 1. Dates of employment: 08/1/2007 ______________ to 12/20/07 ______________ name of employer: Sacramento Valley Chri.Academy ______________________________ type of Business: daycare ____________________ 6097 E. Stockton Blvd Sacramento CA 95823 address: _____________________________________________________________________________
street City state Zip

916-689-2449 Tracee Lewis telephone #: ______________________________ supervisor/Contact name: __________________ 9.00 Your Position: preschool teacher _____________________________ ending salary ___________________________ Your Duties: diapering, feeding, supervision of children, set up of lesson plans and activities _______________________________________________________________________

reason for leaving: Left to move away for school _________________________________________________________________ 2. Dates of employment: 06/2008 ______________ to 07/2008 ______________ name of employer: Asian Community Nursing Home ______________________________ type of Business: Senior nursing facility ____________________ Sacramento, CA 95831 address: 7801 Rush River Dr _____________________________________________________________________________
street City state Zip

telephone #: 916 393-9020 ______________________________ supervisor/Contact name: DON __________________ Your Position: Training cna _____________________________ ending salary 0.00 ___________________________ Your Duties: ADL: diapering, assisting with feeding, clothing, changing linens, socalization _______________________________________________________________________ reason for leaving: end of school service _________________________________________________________________ 3. Dates of employment: 10/30/2006 ______________ to 12/20/2006 ______________ name of employer: Bath and Body Works ______________________________ type of Business: Bathing Store ____________________ address: 9163 E. Stockton Blvd, Elk Grove, ca. 95624 _____________________________________________________________________________
street City state Zip

telephone #: 916-714-9103 ______________________________ supervisor/Contact name: Nicole __________________ Your Position: sales rep/customer service _____________________________ ending salary 7.65 ___________________________ Your Duties: customer service, cashiering, stocking _______________________________________________________________________ reason for leaving: moved to Oklahoma. _________________________________________________________________
09/08

A Not for Profit, 501C(3) Organization

COMMUNITY CATALYSTS
OF CALIFORNIA
Empowering Consumers, Enhancing Lives

An EquAl opportunity EmployEr

EmploymEnt ApplicAtion
pAgE 4

4.

Dates of employment: 08/1/2006 ______________ to 10/30/2006 ______________ Mervyns name of employer: ______________________________ type of Business: Department Store ____________________ n/a address: _____________________________________________________________________________
street City state Zip

telephone #: n/a ______________________________ supervisor/Contact name: n/a __________________ Customer service associate 7.45 Your Position: _____________________________ ending salary ___________________________ Your Duties: cashier, fitting room, stock _______________________________________________________________________ reason for leaving: Seasonal _________________________________________________________________

09/08

A Not for Profit, 501C(3) Organization

COMMUNITY CATALYSTS
OF CALIFORNIA
Empowering Consumers, Enhancing Lives

An EquAl opportunity EmployEr

EmploymEnt ApplicAtion
pAgE 5

PLEASE READ CAREFULLY AND SIGN BELOw: 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 fact 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. I, hereby authorize Community Catalysts of California to thoroughly investigate my references, work record, education and other matters related to my suitability for employment unless I have indicated to the contrary. I, further authorize my former employers to disclose to Community Catalysts of California any and all letters, reports and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release Community Catalysts of California, my 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. In consideration of my employment, I agree to conform to the rules and standards of Community Catalysts of California and agree that my employment and compensation can be terminated at will, at the option of either Community Catalysts of California or myself with or without notice. I understand that no employee or representative of the company has the authority to enter into any agreement for employment for any specified period of time, or to make any express or implied agreement except in writing and approved by the Chief Executive Officer or the Board of Directors. Should I be employed by Community Catalysts of California, I agree that this shall constitute a fully binding agreement with respect to the at-will nature of my employment relationship I am waiving my right to receive written or verbal notification of information obtained by Community Catalysts of California through the reference and pre employment screening process associated to this employment application. AP __________(initial) applicant’s signature: Angelica Polk _____________________________________ Date: 1/06/2009 _______________________

09/08