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Position Applying:
Desired Pay (per hour):

BASIC INFORMATION

Last Name:
First:
Middle:
Street:
Apt. /Ste. #
City:
State:
Zip:
Phone:
Email:
Fax:
Are you 18 years or older?
Are you authorized to work in the U.S.?
How were you referred to Optima Family Services, Inc.?
Is there any information we would need about your name or use of another name for us to be able to check your work record? 
If yes, please specify:
Do you have a valid California Driver’s License?

Please Note:

Optima will consider qualified applicants with criminal histories in a manner consistent with the Los Angeles Fair Chance Initiative for Hiring.

We comply with the ADA and consider reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. Hire may be subject to passing a medical examination, and to skill and agility tests.)

We may refuse to hire relatives of present employees if doing so could result in actual or potential problems in supervision, security, safety, or morale, or if doing so could create conflicts of interest.


EDUCATION

High School/GED:
Date of Graduation/Completion:

Post-Secondary (Undergraduate or Vocational):
Degree/Certificate Earned:
Date of Graduation/Completion:

Graduate:
Degree/Certificate Earned:
Date of Graduation/Completion:

Other (please specify):
Degree/Certificate Earned:
Date of Graduation/Completion:

Please list any additional information such as licenses, certifications, languages, skills, or experience that you
consider important for the job to which you have applied:


PREVIOUS EMPLOYMENT

Employer:
Address:
Contact Person Name & Number:
Position:
From:
to
Reason for Leaving:
May We Contact?

Employer:
Address:
Contact Person Name & Number:
Position:
From:
to
Reason for Leaving:
May We Contact?

Employer:
Address:
Contact Person Name & Number:
Position:
From:
to
Reason for Leaving:
May We Contact?

U.S. MILITARY SERVICE

Branch of Service:
Rank & Type of Service:
Training/Experience Received:

PROFESSIONAL REFERENCES

Name:
Occupation:
Address:
Phone #:
Years Known:
Name:
Occupation:
Address:
Phone #:
Years Known:

APPLICANT AGREEMENT & SIGNATURE

I understand that the employer follows an employment-at-will policy, in that I or the employer may terminate my employment any time, or for any reason consistent with applicable state or federal law. I understand that this application is not a contract of employment. I understand that to be employed I must be lawfully authorized to work in the United States, and I must show the employer documents that will prove this if I am offered the job.

I understand that the company will thoroughly investigate my work, personal, and criminal history and verify all data given on the application, on related papers, and in interviews. I authorize all individuals, schools and firms named within to provide any information requested about me, and I release them from all liability for damage in providing this information.

I certify that all the statements herein are true and understand that any falsification or willful omission shall be sufficient cause for dismissal or refusal of employment.

Name:
Date: