Form LIC 501 at a glance
What it is: The Personnel Record of the California Department of Social Services is a form to be completed by employee.
Who signs: Sign on Signature of employee and enter the Date.
A filled-in Form LIC 501 example: a new employee fills out the record
How to fill out Form LIC 501, box by box
Facility and date
Enter the Date, Name of Facility, Facility Address and Facility File Number.
1. Personal
Under 1. Personal, enter Name (Last First Middle), Telephone and Address, and Are you 18 years of age or older? Yes or No; if no, state your age.
Social Security Number is voluntary for ID only; also enter Date of last physical examination and Date of last TB test.
Have you ever been employed under a different name? Yes or No; if yes, please list all names used.
Do you possess a valid California driver's license? Yes or No, then Has your driver's license ever been suspended or revoked? Yes or No, and enter the CDL number; if yes, please explain on back of form.
Enter Nearest living relative: Name, Telephone number, Relationship and Address.
2. Position
Under 2. Position, enter Title, Salary, Hours, Date of employment and Name of supervisor.
3. Previous employment
Under 3. Previous employment, list most recent experience first: Dates from and to, Name and address of employer, Telephone number, Job title and type of work, and Reason for leaving. If additional space is needed, please attach a separate page.
4. Education
Under 4. Education, circle highest year completed, then Diploma, and Currently enrolled in high school completion course? No or Yes; if yes, give expected completion date.
Under Employment-related education courses, enter Course title, Name of school or organization and address, Number units completed, Date completed and Currently enrolled.
Under 4. Education (Continued), enter Name university, college or business school and address, Major subject, No. of years completed, No. of units completed, Diploma degree or certificate and Date completed.
5. References
Under 5. References, list names of three persons who can give information about your background, character, abilities, etc.: Name, Address, Telephone number and Relationship to you (friend, employer, etc.).
6. Professional and technical qualifications
Under 6. Professional and technical qualifications, list Licenses or Certificates of Competence held in A, Names of Professional Associations of which you are a member in B, and Notes.
Signing the certification
By signing you certify under penalty of perjury that the statements are true and correct, and you give permission for any necessary verification.
Sign on Signature of employee and enter the Date.
Sources
[1] Form LIC 501 (3/99), Personnel Record, California Department of Social Services (the Official source link on this page).
