SUPPLEMENTAL EMPLOYMENT APPLICATION QUESTIONNAIRE
Name: Requisition #: Position Applying to: Email Address: Department: OTHER PERTINENT INFORMATION Do you have any close relative(s) employed by Cal Poly? Yes___ No___ (Please provide detail below) Name(s): Department(s): Relationship(s): Have you ever been convicted of any crime as an adult? (note: do not report traffic citations (tickets) unless they resulted in a felony conviction; DUIs MUST be reported.) A conviction, whether an infraction, misdemeanor or felony, includes a plea, verdict, or finding of guilty, regardless of whether a sentence was imposed by the court. (Note: A conviction will not necessarily disqualify an applicant from employment). The applicant need not provide information about marijuana possession convictions for a violation of Health and Safety Code Section 11357(b) or (c), Section 11360(s), or Section 11364, 11365, or 11550 that occurred more than two years ago. Yes___ No___ (Please include a statement below with type of offense(s), conviction date(s), city and state of conviction(s), final disposition(s), and explanation(s)) AGREEMENT By submitting this Supplemental Employment Application Questionnaire, I certify that all statements made on this questionnaire and the information contained in all other documents I have submitted in support of my application are true and correct and I have not knowingly withheld any factors or circumstances. I understand that my stated pre‐employment qualifications are subject to verification and I hereby authorize Cal Poly to confirm or investigate any information provided. I understand that any falsification of my application materials will be sufficient grounds for rejection of the application, or termination of employment. If selected for employment, I give Cal Poly consent to conduct a criminal records check and may be required to be fingerprinted and/or undergo a medical examination. I understand that as a condition of employment, U.S. citizens are required to sign the State of California's "Oath of Allegiance" and non‐U.S. citizens are required to sign the "Declaration of Permission to Work." Cal Poly only hires individuals lawfully authorized to work in the U.S. If hired, I agree to provide proof of my identity and work authorization as required by the Immigration Reform and Control Act of 1986. Failure to provide appropriate documentation for verification of employment eligibility shall result in immediate termination of employment and/or offer of employment. In submitting this questionnaire, I authorize Cal Poly to release employment information contained herein as necessary to employees and agents of the California State University (CSU) who require such information to investigate or to make a decision with respect to any matter pertaining to my employment. All information provided may be used only for purposes of employment in accordance with the State of California Information Practices Act of 1977. If employed, I understand that, except as may be modified by an applicable collective bargaining agreement for represented employees, including faculty, and/or California State Statue, my employment may be ended at any time, at the option of either Cal Poly or myself for any reason, with or without advance notice. This understanding cannot be changed, except in writing by the Cal Poly HR Director or Vice Chancellor of Human Resources. By signing below, I certify that I have read and agree with the Agreement as stated above. Signature: ____________________________________________________ Date:___________________________ Last Revised: ϭϮͬϬϮ/2014