STD. 678 Instructions

Read the following instructions carefully before completing this application. Please complete the application on a computer or print in ink. All questions must be answered completely and accurately, except as noted. You may be disqualified for any false or misleading statements or for omitting information. The information you furnish will be used to apply for a job, determine your eligibility and/or may be the basis for arriving at your final rating in an examination. During the course of an examination, you may be requested to provide additional information regarding your qualifications, your preference regarding work location, shifts, etc.

Social Security Number (SSN)

Providing this is voluntary in accordance with the Privacy Act of 1974 (PL 93-579). However, a SSN may be needed to process your application when granting items such as Veterans’ Preference, Limited Examination and Appointment Program (LEAP), Career Credits, and/or confirming list eligibility.

Examination(s) or Job Title(s)

Provide the title of the position listed on the announcement.

Question 2

Must be answered by all applicants. You must answer “Yes” if you have ever, because of poor performance or misconduct, been fired, dismissed, or terminated from a job, or had an employment contract terminated. 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who have been rejected during a probationary period, or whose dismissals or terminations have been overturned, withdrawn (unilaterally or as part of a settlement agreement) or revoked need not answer “Yes.” Explain any “Yes” answers in the Explanations section. Briefly describe the facts, findings, any action taken against you, and the circumstances under which you left the position.

In completing this application, you do not need to answer “Yes” to Question 2 if any of the following are true:

• You have been rejected during a probationary period
• Your employer withdrew the firing, dismissal, termination, or contract termination (either voluntarily or as part of a settlement)
• A court or administrative agency overturned or revoked the firing, dismissal, termination, or contract termination

If asked about past employment history by a prospective employer during the hiring process or probationary period, applicants are required to tell the truth regarding any firing, dismissal, termination, contract termination or rejection during probationary period, whether or not the action was overturned, revoked, or withdrawn (either voluntarily by the employer or, as part of a settlement agreement). Applicants are also required to provide factually correct information in the Employment History section of the application.

Question 3

Must be answered by all applicants. Government Code section 18720.45 requires applicants for state employment to disclose on their application form whether they have entered into any agreement(s) with the state in which the applicant agreed to refrain from seeking or accepting any subsequent employment with the state. You must answer “Yes” to this question if you have ever entered into a written agreement with any department, agency, commission, board, state employer, or other governmental unit within California state civil service, where one of the terms of the agreement provided that you agreed not to seek or accept subsequent employment with the state or any state agency. A state agency includes any department, agency, commission, board, state employer, or other governmental unit within the California state civil service, but does not include the California State University.

Question 4

Must be answered by all applicants. Government Code section 18720.45 requires applicants for state employment to disclose on their application form whether they have entered into any agreement(s) with the state in which the applicant agreed to refrain from seeking or accepting any subsequent employment with the state. You must answer “yes” to this question if you have ever entered into a written agreement with any department, agency, commission, board, state employer, or other governmental unit within the California state civil service, involving an adverse action, rejection on probation, or AWOL termination where one of the terms of the agreement provided that you agreed not to seek or accept subsequent employment with a particular state agency. A state agency includes any department, agency, commission, board, state employer, or other governmental unit within the California state civil service, but does not include the California State University. If you answer “Yes” to this question, please provide the name of the particular agency and the details in the Explanations section.

Question 10

If you checked “Yes” and you are not able to attach the Accommodation Request form, you will be contacted via telephone or mail to make specific arrangements.

Explanations

Use this section to explain the details of any response that requires additional information. Be thorough, and attach additional sheet(s) if needed.

Applicant’s Signature

Your signature and the date signed is required. If the hard copy application is not signed, it may be rejected. Electronic submission of your application through a CalCareer Account certifies your application in place of a signature and date signed.

Education

You must include a complete record of your training and educational background. Please read the requirements of the examination bulletin for any specific educational requirements. If more space is needed, you may attach additional documentation.

Licenses

If the examination bulletin requires a specific license, professional certificate, or membership in a professional organization, list the full name of the license, certificate or organization, the license number, and the official the expiration date of the document or membership.

Employment History and Experience

You must include a complete list of your paid and/or volunteer work experience that relates to the qualification requirements specified on the examination bulletin. List all relevant jobs during the past 10 years, regardless of duration, including part-time and military service. You should also list volunteer experience and jobs if they directly relate to the job for which you are applying. State employees must list the specific departments for which they worked and indicate the specific civil service title(s) held.

Requesting Veterans’ Preference

If you have not previously applied and been approved for Veterans’ Preference, you must complete and submit the Veterans’ Preference Form, CALHR-1093 to the California Department of Human Resources.

Equal Employment Opportunity Page

Providing this information is voluntary. This data is only to be used for statistical purposes in evaluating the extent to which the state is complying with state and federal equal employment opportunity and non-discrimination requirements.

NOTE: Your completed application and other examination related information submitted to the department administering this examination becomes confidential information and the property of the State of California as provided by Government Code section 18934. This application and other confidential information will not be returned; therefore, it is recommended that you keep a copy of your completed application for your records. Your rights to inspect your examination papers are set forth in Title 2, section 186 -189 of the California Code of Regulations, which can be accessed at Office of Administrative Law website.

Information About Disability

Physical disability includes but is not limited to having any physiological disease, disorder, condition, cosmetic disfigurement, or anatomical loss that affects one or more of several body systems and limits a major life activity. The body systems listed include the neurological, immunological, musculoskeletal, special sense organs, respiratory, including speech organs, cardiovascular, reproductive, digestive, genitourinary, hemic and lymphatic, skin, and endocrine systems. A physiological disease, disorder, condition, cosmetic disfigurement, or anatomical loss limits a major life activity, such as working, if it makes the achievement of the major life activity difficult.

Mental disability includes but is not limited to having any mental or psychological disorder or condition, such as intellectual or cognitive disability, organic brain syndrome, emotional or mental illness, or specific learning disabilities, that limits a major life activity, or having any other mental or psychological disorder or condition that requires special education or related services.

Major life activities are defined broadly and include physical, mental, and social activities, including but not limited to, caring for oneself, performing manual tasks, seeing, hearing, eating, sleeping, walking, standing, sitting, reaching, lifting, bending, speaking, breathing, learning, reading, concentrating, thinking, communicating, interacting with others, and working. Major life activities include the operation of major bodily functions, including functions of the immune system, special sense organs and skin, normal cell growth, digestive, genitourinary, bowel, bladder, neurological, brain, respiratory, circulatory, cardiovascular, endocrine, hemic, lymphatic, musculoskeletal, and reproductive functions.

Major bodily functions include the operation of an individual organ within a body system.

An impairment “limits” a major life activity if it makes the achievement of the major life activity difficult.

Medical condition is defined as any health impairment related to or associated with a diagnosis of cancer or a record or history of cancer, or a genetic characteristic.

Genetic characteristic is defined as any scientifically or medically identifiable gene or chromosome or an inherited characteristic that could statistically lead to increased development of a disease or disorder.

California Code of Regulations, Title 2, section 11065.