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A Not for Profit, 501C(3) Organization

Employment Application
COMMUNITY CATALYSTS An Equal Opportunity Employer
OF CALIFORNIA Page 1
Empowering Consumers, Enhancing Lives

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

Social Security#: 615-44-3531

_____________________________ Date: ____________________________________
1/6/2009
Name (Last, First MI): ______________________________________________________________________
Polk, Angelica
Address: 8278
________________________________________________________________________________
Grandstaff Drive Sacramento, Ca 95823
Permanent Address if different from present address: ______________________________________________
________________________________________________________________________________________
Home Phone #: 916-956-2449
______________________________ Message Phone: ___________________________

EMPLOYMENT DESIRED:

For which job/position are you applying?: ______________________________________________________

direct service aide

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
Would you be available to work over time, if necessary? Yes No
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? Yes No
If yes, when and which office? ___________________________________________________
Do you have friends or relatives working for Community Catalysts of California? Yes No
If yes, state name(s) and relationship: _____________________________________________
Why are you applying for work at Community Catalysts of California? _________________________________
I am applying so that I can put my care
________________________________________________________________________________________
giver skills to good use.

If hired, would you have a reliable means of transportation to and from work? Yes No

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 A Not for Profit, 501C(3) Organization
Employment Application
COMMUNITY CATALYSTS An Equal Opportunity Employer
OF CALIFORNIA Page 2
Empowering Consumers, Enhancing Lives

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? Yes No

EDUCATION, TRAINING AND EXPERIENCE

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
work at Community Catalysts of California? If so, please explain: ____________________________________
Experience working with a diverse variety of
________________________________________________________________________________________
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.
Credentials
School Major or Course Certification/
Degree
College Consumnes River College Criminal Justice cna certification
other Valley Highschool general highschool diploma
other

09/08
 A Not for Profit, 501C(3) Organization
Employment Application
COMMUNITY CATALYSTS An Equal Opportunity Employer
OF CALIFORNIA Page 3
Empowering Consumers, Enhancing Lives

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
____________________
Address: _____________________________________________________________________________
6097 E. Stockton Blvd Sacramento CA 95823
Street City State Zip

Telephone #: ______________________________
916-689-2449 Supervisor/Contact Name: __________________
Tracee Lewis
Your Position: preschool
_____________________________
teacher Ending Salary ___________________________
9.00
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
Address: 7801
_____________________________________________________________________________
Rush River Dr Sacramento, CA 95831
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
Employment Application
COMMUNITY CATALYSTS An Equal Opportunity Employer
OF CALIFORNIA Page 4
Empowering Consumers, Enhancing Lives

4. Dates of Employment: 08/1/2006

______________ to 10/30/2006
______________
Name of Employer: ______________________________ Type of Business: Department
Mervyns ____________________
Store
Address: n/a
_____________________________________________________________________________
Street City State Zip

Telephone #: n/a
______________________________ Supervisor/Contact Name: n/a
__________________
Your Position: _____________________________ Ending Salary ___________________________
Customer service associate 7.45
Your Duties: cashier,
_______________________________________________________________________
fitting room, stock

Reason for Leaving: Seasonal

_________________________________________________________________

09/08
 A Not for Profit, 501C(3) Organization
Employment Application
COMMUNITY CATALYSTS An Equal Opportunity Employer
OF CALIFORNIA Page 5
Empowering Consumers, Enhancing Lives

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
_______________________

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