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GREATER LOS ANGELES AGENCY ON DEAFNESS, INC. (GLAD) 2222 LAVERNA AVENUE, LOS ANGELES, CA 90041 [323] 478-8000 TTY/Voice; [323] 550-4265 FAX; www.gladinc.org

AN EQUAL OPPORTUNITY EMPLOYER

INSTRUCTIONS: This application is part of the application process. It must be completely filled out and signed to be accepted for review. Incomplete applications will be rejected.

POSITION APPLIED FOR:

DATE:

LAST NAME:

FIRST NAME:

MIDDLE INITIAL:

ADDRESS:

CITY:

STATE:

ZIP CODE:

HOME PHONE:

OTHER PHONE:

E-MAIL:

DRIVER LICENSE:

NUMBER:

STATE:

CLASS: ______________

EXPIRATION DATE: _____________

CITIZENSHIP: Are you a U.S. citizen OR do you have authorization to work in the U.S.?   Yes  No

Proof of citizenship or immigration will be required upon employment.

CONVICTIONS:

Conviction of a crime is not necessarily a bar from employment. Each case is considered separately based on job requirements. However, failure to list convictions, except as provided below may result in termination from examination process or employment.

Have you ever been convicted by a court of a crime? Yes No

Omit:

           a) Minor traffic violations (Driving Under the Influence Convictions must be reported).

b) Any offense committed prior to your 18th birthday that was finally adjudicated in Juvenile Court or under a youth offender law.

c) Any incident sealed under Welfare and Institutions Code §781 or Penal Code 1203.45.    

If “YES”, state WHAT Offense, WHEN, WHERE, AND DISPOSITION OF CASE:

___________________________________________________________________________________

___________________________________________________________________________________

______________________________________________________________________________________________________________________________________________________________________

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