Per-Diem Program Support Employment Application

We appreciate your interest in our organization and are sincerely interested in your background and qualifications. Please answer all questions as thoroughly as possible so we may review this information in consideration of employment within our organization. We consider all applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, sexual orientation, or any other legally protected status.

This position is per diem with a pay range of $20-$25/hr.

Personal

Date:

Last Name:

First Name:

Middle Name:

Address:

Address

City/Town

State/Province

ZIP/Postal Code

Email Address:

Telephone No.:

Please select the program(s) you are interested in:

Healthy Cooking with Kids

Congregate Meals

In partnership with Benicia Unified School District, Healthy Cooking with Kids aims to provide students with fundamental cooking skills and basic nutrition education.

Find out more about Healthy Cooking with Kids here.

The Congregate Meals program serves nutritious, heart healthy diabetic friendly lunches to older adults in a group setting with an opportunity to socialize with others and get involved in fun activities.

Find out more about Congregate Meals here.

Do you have experience working with kids or older adults? Please specify and describe the responsibilities and role.

What is your experience working with diverse populations?

What is your availability Monday - Friday?

Do you have a reliable source of transportation?

Yes

No

Are you legally eligible for employment in the U.S.A.?

Yes

No

Are you 18 years or older?

Yes

No

Are you employed now?

Yes

No

If yes, may we contact your present employer?

Yes

No

If your application is considered favorably, on what date will you be available for work?

Have you had any criminal convictions?

Yes

No

Conviction Record Information

If you answered YES to the criminal conviction question on this form and have been convicted of a felony or misdemeanor, please list the specific nature and details of the offense(s), date(s), court location, sentencing information, rehabilitation completed, an disposition of sentence.

Americans with Disabilities Act Clarification

With or without reasonable accommodation, can you perform the essential job functions for the position you have applied for?

Yes

No

Military Service

Branch:

Years served:

Rank:

File Uploads

Cover Letter and Resume

Upload requirements

Signatures

PLEASE READ AND SIGN BELOW

"I" CERTIFY THAT THE FACTS CONTAINED IN THIS APPLICATION ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT, IF EMPLOYED, FALSIFIED STATEMENTS ON THIS APPLICATION SHALL BE GROUNDS FOR DISMISSAL.

I AUTHORIZE INVESTIGATION OF ALL MY STATEMENTS CONTAINED HEREIN AND THE REFERENCES LISTED ABOVE TO GIVE YOU ANY AND ALL INFORMATION THEY MAY HAVE, PERSONAL OR OTHERWISE, AND RELEASE ALL PARTIES FROM LIABILITY FOR ANY DAMAGE THAT MAY RESULT FROM FURNISHING SAME TO YOU.

I UNDERSTAND AND AGREE THAT, IF HIRED, MY EMPLOYMENT IS FOR NO DEFINITE PERIOD AND MAY, REGARDLESS OF THE DATE OF PAYMENT OF MY WAGES OR SALARY, BE TERMINATED AT ANY TIME WITHOUT ANY PRIOR NOTICE."

Signature:

Date: