Staff Application

Thank you for your interest in Trauma Intervention Programs of San Diego, Inc. Please complete and submit the following application. If you have any questions, please contact us at (855) 847-7343 or info@tipsandiego.org.

Personal History Statement

The following information is requested of you for verification and contact purposes:

Full Name

Other Names (including nicknames) you have used or been known by:

Address at which you can be contacted.

City

State

Zip Code

Telephone

Cell Phone

In accordance with the Federal Privacy Act of 1974, disclosure is voluntary. The SSN will be used for identification purposes to ensure that proper records are obtained.

Last four digits of Social Security Number

REFERENCES
During the course of the background investigation, persons who know you will be asked to comment upon your suitability for a position with Trauma Intervention Programs of San Diego County, Inc. In the space below, please list at least three individuals (no more than 1 personal) who have known you for at least two years. Exclude former employers. If a category is not applicable, write in N/A.

Name

Occupation

Relationship

Telephone

Cell Phone

Address

City

State

Zip

Length of time known

Name

Occupation

Relationship

Telephone

Cell Phone

Address

City

State

Zip

Length of time known

Name

Occupation

Relationship

Telephone

Cell Phone

Address

City

State

Zip

Length of time known

EMERGENCY CONTACT

Name

Relationship

Telephone

Cell Phone

Address

City

State

Zip

EDUCATION

Please check the appropriate box(es):

I possess a high school diploma from a U.S. institution I passed the G.E.D. (General Educational Development) test. I passed the California High School Proficiency Examination. I possess a two-year college degree. I possess a four-year college or university degree. I do not currently have a high school diploma or its equivalent, but I plan to satisfy the requirement in the future as follows:

Please indicate below all the schools you have attended beginning with high school. During the background investigation, persons who have known you in a learning environment may be contacted. A review of your school records may be made in conjunction with those contacts. If a category is not applicable, write in N/A.

Name of School

Address of School

Dates Attended

School References (teachers, counselors, etc.)

Name of School

Address of School

Dates Attended

School References (teachers, counselors, etc.)

Name of School

Address of School

Dates Attended

School References (teachers, counselors, etc.)

Name of School

Address of School

Dates Attended

School References (teachers, counselors, etc.)

EXPERIENCE AND EMPLOYMENT
Beginning with your most current employment, please list all jobs (including part-time, temporary, military service positions) you have held in the past 10 years. If you have had intervening periods of unemployment, please list those periods in sequence in the spaces provided. If a category is not applicable, write in N/A.

Dates of employment

Name and address of employer

Telephone and Email

Name of supervisor

Status

Full Time Part Time Volunteer

Title or duties

Reason for Leaving

Name(s) of co-worker(s)

Not Employed

Dates of Unemployment

Dates of employment

Name and address of employer

Telephone and Email

Name of supervisor

Status

Full Time Part Time Volunteer

Title or duties

Reason for Leaving

Name(s) of co-worker(s)

Not Employed

Dates of Unemployment

Dates of employment

Name and address of employer

Telephone and Email

Name of supervisor

Status

Full Time Part Time Volunteer

Title or duties

Reason for Leaving

Name(s) of co-worker(s)

Not Employed

Dates of Unemployment

MISCELLANEOUS

Please list any other experience, job related skills, additional languages, or other qualifications that you believe should be considered in evaluating your qualifications for employment.

LEGAL
Have you ever been convicted of a crime, excluding minor traffic violations? If so, please provide the following information:

Date, Charges, and Disposition:

GENERAL INFORMATION

On what date are you available to begin work?

Are you available to work?

Are you available to work nights and/or weekends?

Upload Resume

APPLICANT STATEMENT AND AGREEMENT
Please read and check off each paragraph below. If there is anything that you do not understand, please ask.

I hereby authorize the Company to thoroughly investigate my references, work record, education and other matters related to my suitability for employment and, further, authorize the prior employers and references I have listed to disclose to the Company 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 the Company, 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.

In the event of my employment with the Company, I understand that I am required to comply with all rules and regulations of the Company.

If hired, I understand and agree that my employment with the Company is at‐will, and that neither I, nor the Company is required to continue the employment relationship for any specific term. I further understand that the Company or I may terminate the employment relationship at any time, with or without cause, and with or without notice. I understand that the at‐will status of my employment cannot be amended, modified, or altered in any way by any oral modifications.

I hereby certify 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 shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery.

I understand that if I am selected for hire, it will be necessary for me to provide satisfactory evidence of my identity and legal authority to work in the United States, and that federal immigration laws require me to complete an I‐9 Form in this regard.

Signature

Date

Thank you for your time in completing the personal history statement. If you have any questions, please call (760) 518-5430.

Personal History Statement

Stay Connected

Follow Us

Made with ♥ by WebSites San Diego
Creative Design by R. Corral