SOUTHEAST REGIONAL OCCUPATIONAL PROGRAM
  APPLICATION FOR EMPLOYMENT
20122 Cabrillo Lane                                  
Cerritos, CA 90703     (562) 860-1927
CIRCLE ALL CHOICES THAT APPLY:      full-time     part-time       days       evenings          mon      tue      wed      thu      fri      sat
POSITION APPLIED FOR:________________________________________________________________________
PLEASE PRINT Date available for employment          
Name                       Social Security #        
Last First MI
Address                   Phone   (              )              
City         State:     Zip     Message phone    (             )          
                                     
EMPLOYMENT HISTORY
List ALL relevant employment, beginning with your present, or most recent employment, list at least the last five years,  
 list military experience,  if job related.  If necessary, use additional sheet of paper.  
   
NAME OF EMPLOYER:               TYPE OF BUSINESS:        
   
ADDRESS:                 PHONE  (        )        
   
Starting Title         Last Title                    
   
Dates of employment (month & year) from:     to:   full / part time?    
   
Name and title of supervisor:                       May we contact now?
  (circle)   Yes     No
   
Last Salary       Reason for leaving                    
   
Describe work performed:                            
                                   
                                     
   
NAME OF EMPLOYER:               TYPE OF BUSINESS:        
   
ADDRESS:                 PHONE  (        )        
   
Starting Title         Last Title                    
   
Dates of employment (month & year) from:     to:   full / part time?    
   
Name and title of supervisor:                       May we contact now?
  (circle)   Yes     No
   
Last Salary       Reason for leaving                    
   
Describe work performed:                            
                                   
                                   
                                     
EDUCATION AND TRAINING
High School Last Attended: City, State Major Subjects Graduate:  Yes____No___  
                                     
College or University              City, State     Dates Attended Major Subjects Degree  
                  to                  
Other classes/training   City, State Dates Attended Course/Training  
                  to                  
List college degrees, credentials, certificates, and any other information         
   
                                     
GENERAL INFORMATION        
Have you ever been convicted of a misdemeanor or felony (except minor traffic violations:  drunk, reckless or hit-run   
driving are not minor traffic violations)?  
   
Complete the following in your OWN HANDWRITING:  
   
I have_________________________________________________________OF A MISDEMEANOR OR FELONY.
(never been convicted)  
I have ___________________________________________________OF A MISDEMEANOR OR FELONY;  AND
(been convicted)  
THE FOLLOWING ARE THE CIRCUMSTANCES AND DATES:                  
                                     
                                     
Do you have any physical limitations or health problems that could prevent you from successfully performing the job for which you   
are applying?        No               Yes:   EXPLAIN                          
                                     
                                     
PERSONAL REFERENCES
(Give three - do not include previous employers or relatives.)          
Name         Address & City, State Zip   Occupation     Business Phone      
         
                                     
         
                                     
         
                               
READ CAREFULLY BEFORE SIGNING                    
   
I hereby certify that all statements made on this application are true and complete to the best of my knowledge.  
I understand and agree that any false or incomplete statements or omissions of material facts shall be   
sufficient cause for disqualification from consideration for employment or dismissal.  
   
   
   
                                   
Signature Date  
   
NOTE: Applicant / employee must submit to:  
  1.  Fingerprinting / photographing  
  2.  Pre-employment Physical examination and Tuberculosis examination  
  3.  Have and maintain a clear DMV record