HTML Preview Standard Job Application Form Printable page number 1.
Applications will be processed ONLY for classifications where an
examination is in progress and the published final filing date has not passed,
or for vacant positions where a department requests an application.
PRINT OR TYPE--PLEASE SEE INSTRUCTIONS ON BACK PAGE
FIRST 3 LETTERS OF
LAST NAME AT BIRTH
MONTH OF BIRTH DAY OF BIRTH
Last 4 DIGITS OF SOCIAL
SECURITY NUMBER
EASY ID
APPLICANT'S NAME (Last)
(First)
(M.I.)
SOCIAL SECURITY NUMBER
MAILING ADDRESS (Number) (Street)
E-MAIL ADDRESS
WORK TELEPHONE NUMBER
(City) (County) (State) (Zip Code)
HOME/VRS/TTY TELEPHONE NUMBER
EXAMINATION(S) OR JOB TITLE(S) FOR WHICH YOU ARE APPLYING
ANSWER THE FOLLOWING QUESTIONS:
PERSONNEL
USE ONLY
1. Enter the county in which you would like to take the examination
if different from the county of your residence:
2. Do you need reasonable accommodation to take an interview or written test? Yes No
3. Do your religious beliefs prevent you from taking an examination on Saturday?
Yes No
4. Are you now employed by the State of California? (If "YES", fill in the information below.)
Yes No
Department: Subdivision
5. Have you ever been fired, dismissed, terminated, or had an employment contract terminated from any position for
performance or for disciplinary reasons? (Applicants who have been rejected during a probationary period, or whose
dismissals or terminations have been overturned, withdrawn [unilaterally or as part of a settlement agreement] or revoked
need not answer "Yes".) Refer to the Instructions for further information. If "Yes" to Question #5, give details in the
Explanations section.
Yes No
a. possess verbal fluency in
b. possess written fluency in
6. In addition to English, list any other languages you:
7. I certify I can type at a speed of
words per minute. (For typing applicants only.)
(ANSWER QUESTIONS 8 AND 9 ONLY IF THE EXAMINATION INDICATES THEY ARE REQUIRED.)
8. Do you meet the minimum and/or maximum age requirements?
Yes No
License #
Class:
Restrictions:
9. Do you possess a valid California Driver License? (If "YES", fill in the information below.)
Yes No
EXPLANATIONS
DATE SIGNED
APPLICANT IDENTIFICATION NUMBER (EASY ID)
CERTIFICATION – IMPORTANT – PLEASE READ BEFORE SIGNING – If not signed, this application may be rejected.
I certify under penalty of perjury that the information I have entered on this application is true and complete to the best of my knowledge. I further understand
that any false, incomplete, or incorrect statements may result in my disqualification from the examination process or dismissal from employment with the
State of California. I authorize the employers and educational institutions identified on this application to release any information they may have concerning
my employment or education to the State of California.
APPLICANT'S SIGNATURE
APPLICANTS—DO NOT USE THE SPACE BELOW—FOR PERSONNEL USE ONLY
Classes
01 02 03 04 05 06
WC for
Series/Levels
RC/Flag for
Series/Levels
CODES
Flags
WC
FOR PERSONNEL USE ONLY
STATUS
Accepted
REJECTED WC
EXPERIENCE
LICENSE REQUIREMENT
EDUCATION OTHER
STAFF DATE PROCESSED
STATE OF CALIFORNIA - CALIFORNIA DEPARTMENT OF HUMAN RESOURCES
EXAMINATION / EMPLOYMENT APPLICATION
STD. 678 (REV. 10/2013) Page 1
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