LOS ANGELES UNIFIED SCHOOL DISTRICT



LOS ANGELES UNIFIED SCHOOL DISTRICT

APPLICATION FOR TEMPORARY WORK

|JOB TITLE OF TEMPORARY | |

| |      |

|ASSIGNMENT REQUESTED | |

|                  | |(     )       -       |

|Last Name First Name Middle Initial | |Home Phone Number |

|Address |      |City/State/Zip Code |     ,            |

|Social Security Number |     -     -      |Are you at least 18 years of Age? | Yes No |

|List Any Languages in addition to English in which you are proficient |

|      | Speak Only Speak, Read, Write |

|ARE YOU NOW OR HAVE YOU EVER BEEN EMPLOYED BY THE LOS ANGELES UNIFIED SCHOOL DISRICT? |Yes No |

|Job Title |      |School or Office |      |

|Date Employed |From |     /     /      |To |     /     /      |Employee Number |      |

|Name if Different from Above |      |

EDUCATION:

Do you have a High School Diploma? Yes No

Have you passed the GED? Yes No

Have you completed a formal (indentured) apprenticeship program? Yes No

If “Yes,” in what trade or craft?      

|Trade School Attended |      |

|College/University Attended |      |

|Major |      |Degree | Yes No |

LIST ANY COURSEWORK YOU HAVE COMPLETED WHICH FULFILLS A JOB REQUIREMENT FOR CLASSIFICATION REQUESTED:

|Course |      |Units |      Sem. Qtr |Completed |      |

|Course |      |Units |      Sem. Qtr |Completed |      |

LIST ANY REQUIRED LICENSES/CERTIFICATES:

|License/Certificate |      |Expires |     /     /      |

|Driver’s License Number |      |Expires |     /     /      |

Do you have the use of an automobile? Yes No

SKILLS:

Can you type? Yes No

Model of computer with which you are familiar (IBM, Macintosh, etc.)      

Software programs with which you are familiar (Word, Excel, etc.)      

List relevant work experience      

I UNDERSTAND THAT THIS IS ONLY AN APPLICATION FOR TEMPORARY EMPLOYMENT. PERMANENT EMPLOYMENT CAN ONLY BE OBTAINED THROUGH THE COMPETITIVE EXAMINATION PROCESS. IF YOU HAVE A CONVICTION RECORD ASK FOR AND COMPLETE THE CONVICTION RECORD FORM. A CONVICTION RECORD DOES NOT AUTOMATICALLY BAR YOU FROM EMPLOYMENT

I HEREBY CERTIFY THAT THE INFORMATION ON THIS FORM IS TRUE.

Date ___________________ Signature ________________________________________________________________

FOR OFFICE USE ONLY

RATING _________________________________

Assignment Area Availability: ____________________________________________________ Test Date____________________

APPLICANT IS:

( ) PROVISIONAL, MEETS ENTRANCE QUALIFICATIONS OF CLASSIFICATION

( ) CONDITIONAL, DOES NOT MEET THE FOLLOWING REQUIREMENT:

( ) EXPERIENCE ( ) EDUCATION ( ) DEGREE

( ) LICENSE/CERTIFICATE ( ) TYPING ( ) SHORTHAND

REVIEWED BY ______________________________________________________________ DATE_____________________

CLASSIFIED EMPLOYMENT OFFICES

( ) BRANCH ( ) EAST ( ) MID CITIES ( ) VALLEY

PC Form 6003 (Rev. 08/06)

APPLICATION FOR TEMPORARY WORK

LIST RECENT WORK EXPERIENCE AND OTHER EXPERIENCE RELATED TO THE JOB FOR WHICHYOU ARE APPLYING

|Name of Company |      | |      |

| |Title or Position Held |

|      | | | |

|Address |Date: |From |     /     /      |

|                  | |To |     /     /      |

|City State Zip Code | |Salary | |

| | |Reason for Leaving |

|      | |      |

|Name/Title of Immediate Supervisor | |      |

| | | |

|Duties: |      |

|Name of Company |      | |      |

| |Title or Position Held |

|      | | | |

|Address |Date: |From |     /     /      |

|                  | |To |     /     /      |

|City State Zip Code | |Salary | |

| | |Reason for Leaving |

|      | |      |

|Name/Title of Immediate Supervisor | |      |

| | | |

|Duties: |      |

|Name of Company |      | |      |

| |Title or Position Held |

|      | | | |

|Address |Date: |From |     /     /      |

|                  | |To |     /     /      |

|City State Zip Code | |Salary | |

| | |Reason for Leaving |

|      | |      |

|Name/Title of Immediate Supervisor | |      |

| | | |

|Duties: |      |

The Los Angeles Unified School District intends that all qualified persons shall have equal opportunities for Employment and promotion and that qualified women, minority groups and the disabled shall be fairly represented on the District work force at all levels

PC Form 6003 (Rev. 08/06)

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