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| last name: | (required) |
| first name: | (required) |
| middle initial: | (required) |
| home phone: | (required) |
| email: | (required) |
| street: | (required) |
| city: | (required) |
| state: | (required) |
| zip: | (required) |
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| department: | (required) |
| year in school: | (required) |
| GPA: | (required) |
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(With the most recent experience listed first, present your present and
past performance; also include any major volunteer experience. Attach
additional sheets if necessary).
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| name of present/recent employer: | |
| may we contact employer: | |
| address 1: | |
| address 2: | |
| telephone: | |
| posistion title: | |
| hours/week: | |
| from (mo/yr): | |
| to (mo/yr): | |
| name of supervisor: | |
| title of supervisor: | |
| reseason for leaving: | |
| salary/wage: | |
| job duties: | |
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| name of present/recent employer: | |
| may we contact employer: | |
| address 1: | |
| address 2: | |
| telephone: | |
| posistion title: | |
| hours/week: | |
| from (mo/yr): | |
| to (mo/yr): | |
| name of supervisor: | |
| title of supervisor: | |
| reseason for leaving: | |
| salary/wage: | |
| job duties: | |
|
| name of present/recent employer: | |
| may we contact employer: | |
| address 1: | |
| address 2: | |
| telephone: | |
| posistion title: | |
| hours/week: | |
| from (mo/yr): | |
| to (mo/yr): | |
| name of supervisor: | |
| title of supervisor: | |
| reseason for leaving: | |
| salary/wage: | |
| job duties: | |
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(List languages understood and spoken fluently, other than English).
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| spoken languages: | (required) |
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(Have you worked with Macintosh or PC Computers?).
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| computer experience: | (required) |
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(What software programs are you experienced with?).
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| software programs: | (required) |
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| other skills: | (required) |
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| please list the days and shifts you are available to work this quarter: | (required) |
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1. Have you ever been convicted of any crime, excluding convictions
for marijuana-related offenses for personal use more than two years
old, convictions that have been sealed, expunged or legally eradicated,
or misdemeanors for which probation was completed and the case was
dismissed by court? If yes, please briefly describe the nature of the
crime(s), the date and place of conviction, and the legal disposition
of the case.
Note: A yes response will not necessarily disqualify you from
consideration for employment.
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| : | (required) |
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2. Have you ever been released or discharged from employment or
resigned to avoid such release or discharge? If yes, please state date
and circumstances.
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| : | (required) |
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3. Do you have a valid California driver's license?
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| : | (required) |
how did you hear about the interviewer position with the center?
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| friend currently working at center (NAME OF PERSON): | |
| friend of previous employee at the center (NAME OF PERSON): | |
| advertisement (WHICH): | |
| other (PLEASE DESCRIBE): | |
Certification and Authorization
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I certify that the information contained on this application form is
true, correct and complete to the best of my knowledge. I understand
that any false or incomplete information may be grounds for
disqualification or separation. In addition, I understand that a
thorough reference checking process will occur and hereby authorize
UCSB to make inquires regarding my education, work experience and
references, unless otherwise stated. I hereby release all parties and
persons associated with any such inquiries from liability in connection
with information they provide. I understand that certain positions my
require background checks including a request for criminal history
information. I have read and understand the information on this
application.
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| email: | (required) |
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