______________________________________________________________________________
An Equal Opportunity and Affirmative Action Employer
Public Policy Institute of California
Part 1: Application for Employment
Page 1 of 3
Last Name: Address: Home phone: City:
First Name: State: Cell phone:
Middle Initial: Zip Code: Email:
Position desired: Salary desired for this position: If you are employed now, may we contact your present employer? If you have applied to PPIC before, for which position was that? How did you learn of this opening? If you have any relatives or acquaintances at PPIC, please provide their name(s): Yes No
If hired, can you provide verification of your legal right to work in the United States? Yes If you are less than 18 years of age, can you furnish a work permit if hired? Yes
No No
Have you been convicted of a criminal offense (a felony or a serious misdemeanor)? Convictions for marijuana-related offenses that are more than two years old need not be listed. Yes No If yes, please explain:
Please note that no applicant will be denied employment solely on the grounds of conviction of a criminal offense. However, the nature of the offense, the date, the surrounding circumstances and the relevance of the offense to the position applied for may be considered.
List your skills as they related to your qualifications as an applicant for this position: Software skills: Foreign language skills (if applicable to this position): Other special skills:
______________________________________________________________________________
An Equal Opportunity and Affirmative Action Employer
Public Policy Institute of California
Part 1: Application for Employment
Page 2 of 3
List your education, including the name and location of school, years of attendance, majors, minors and other areas of emphasis, and graduation date (if applicable): 1 (most recent): 2: 3: 4: 5: Summarize your prior employment, including employer’s name, job title, dates of employment, and name, title, and contact phone number of a reference for this job: 1 (most recent): 2: 3: 4: 5:
Please read each paragraph carefully and indicate that you have done so by checking the box: I understand and agree that, under the Immigration Control and Reform Act of 1986, I must furnish satisfactory evidence of my authorization to work in the United States and that this evidence must be provided on or before my third day of employment. Yes No
I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of material fact on this application or on any document used to secure employment, including my resume, shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery. Yes No
______________________________________________________________________________
An Equal Opportunity and Affirmative Action Employer
Public Policy Institute of California
Part 1: Application for Employment
Page 3 of 3
I hereby authorize PPIC to thoroughly investigate my references, work record, education, and other matters related to my suitability for employment and, further, authorize the references I have listed to disclose to PPIC any and all letters, reports, and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release PPIC, my former employers, and all other persons, corporations, partnerships, and associations from any and all claims, demands, or liabilities arising out of or in any way related to such investigation or disclosure. Yes No
I understand that nothing contained in the application, or covered during any interview that may be granted, or during my employment, if hired, is intended to create an employment contract between PPIC and me. I understand that employment at PPIC is “at will,” which means that if I am employed, my employment is for no definite or determinable period and may be terminated at any time, with or without prior notice, at the option of either myself or the company, and that no promises or representations contrary to the foregoing are binding on PPIC unless made in writing and signed by me and a delegated representative of PPIC. Yes No
Applicant’s Signature: _________________________________________ Date: ______________________ You will be asked to sign this application in person if you are invited to interview at PPIC.
______________________________________________________________________________
An Equal Opportunity and Affirmative Action Employer
Public Policy Institute of California
Optional: Part 2 - PRE-EMPLOYMENT DATA RECORD
Please note: YOUR COOPERATION ON PART 2 IS VOLUNTARY. INCLUSION OR EXCLUSION OF ANY OF THE FOLLOWING DATA WILL NOT AFFECT ANY EMPLOYMENT DECISION. Applicants and employees are treated during the employment process without regard to race, color, religion, sex, national origin, age, marital or veteran status, physical or mental disability, or any other legally protected status. The purpose of this Data Record is to comply with government record keeping, reporting, and other legal requirements. Periodic reports are made to the government on the information below. The completion of this Data Record is optional. If you choose to volunteer the requested information, please note that all data records are kept in a Confidential File and are NOT a part of your application for employment or personnel file. Government agencies at times require periodic reports on the sex, ethnicity, and other protected status of employees and those applying for employment. This data is for statistical analysis with respect to the success of our Equal Employment Opportunity program. Again: this data will not affect any employment decision.
VOLUNTARY SURVEY Name: Check one of the following: Female
Date:
Position applied for:
Male
Check one of the following: (Ethnic Origin) American Indian/Alaskan - Definition: all persons having origins in any of the original peoples of
North America and who maintain cultural identification through tribal affiliation or community recognition. Asian/Pacific Islander - Definition: all persons having origins in any of the original peoples of the Far East, Southeast Asia, the Indian Subcontinent, or the Pacific Islands. This area includes, for example, China, Japan, Korea, the Philippine Islands, and Samoa. Black (not of Hispanic origin) – Definition: all persons having origins in any of the black racial groups of Africa. Hispanic – Definition: all persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of race. White (not of Hispanic origin) - Definition: all persons having origins in any of the original peoples of Europe, North Africa, or the Middle East.
If any of the following are applicable, check one: Vietnam Era Veteran – Definition: a person who served on active duty for more than 180 days, and who
was discharged or released other than dishonorably, any time in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or between August 5, 1964, and May 7, 1975, in all other cases; or who was discharged or released from active duty for service-connected disability if any part of such act of duty was performed in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or between August 5, 1964, and May 7, 1975, in all other cases. Newly Separated Veteran - Definition: a person who served on active duty in the U.S. military ground, naval, or air service during the one-year period beginning on the date of such veteran's discharge or release from active duty. To clarify, Newly Separated Veterans are considered as such during the year after they are released or discharged from active duty. Other Veteran - Definition: a person who served on active duty during a war (e.g., Korea), campaign (e.g., Desert Shield/Storm), or expedition (e.g., Persian Gulf, Panama) for which a campaign badge has been authorized.