Fill and Sign the Arizona Joint Tax Application 2015 Form

STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES DATE PERSONNEL RECORD (Form to be completed by employee) NAME OF FACILITY FACILITY ADDRESS FACILITY FILE NUMBER 1. NAME (LAST FIRST PERSONAL TELEPHONE MIDDLE) ( ADDRESS ) ARE YOU 18 YEARS OF AGE OR OLDER? YES NO IF NO, PLEASE STATE YOUR AGE s s _____________________________ SOCIAL SECURITY NUMBER: (VOLUNTARY FOR ID ONLY) - DATE OF LAST PHYSICAL EXAMINATION DATE OF LAST TB TEST - HAVE YOU EVER BEEN EMPLOYED UNDER A DIFFERENT NAME? DO YOU POSSESS A VALID CALIFORNIA DRIVER'S LICENSE? s s YES YES s s NO IF YES, PLEASE LIST ALL NAMES USED. NO HAS YOUR DRIVER'S LICENSE EVER BEEN SUSPENDED OR REVOKED? CDL NUMBER NEAREST LIVING RELATIVE — NAME: IF YES, PLEASE EXPLAIN ON BACK OF FORM. TELEPHONE NUMBER s YES s NO RELATIONSHIP ADDRESS 2. POSITION TITLE SALARY HOURS DATE OF EMPLOYMENT NAME OF SUPERVISOR 3. PREVIOUS EMPLOYMENT (List most recent experience first. If additional space is needed, please attach a separate page.) TELEPHONE JOB TITLE AND DATES REASON FOR NAME AND ADDRESS OF EMPLOYER NUMBER FROM TO TYPE OF WORK LEAVING 4. CIRCLE HIGHEST YEAR COMPLETED 6 7 8 9 10 11 12 DIPLOMA EDUCATION CURRENTLY ENROLLED IN HIGH SCHOOL COMPLETION COURSE? s NO s YES IF YES, GIVE EXPECTED COMPLETION DATE___________________ EMPLOYMENT — RELATED EDUCATION COURSES NAME OF SCHOOL OR ORGANIZATION COURSE TITLE AND ADDRESS LIC 501 (3/99) (OVER) NUMBER CURRENTLY DATE UNITS COMPLETED COMPLETED ENROLLED 4. EDUCATION (Continued) NAME UNIVERSITY, COLLEGE OR BUSINESS SCHOOL AND ADDRESS MAJOR SUBJECT 5. NO. OF YEARS COMPLETED NO. OF UNITS COMPLETED DIPLOMA DEGREE OR DATE CERTIFICATE COMPLETED REFERENCES List names of three persons who can give information about your background, character, abilities, etc. NAME ADDRESS 6. TELEPHONE NUMBER RELATIONSHIP TO YOU (FRIEND, EMPLOYER, ETC.) PROFESSIONAL AND TECHNICAL QUALIFICATIONS A. List Licenses or Certificates of Competence held: B. Names of Professional Associations of which you are a member: NOTES: I hereby certify under penalty of perjury that the above statements are true and correct. I give my permission for any necessary verification. SIGNATURE OF EMPLOYEE DATE