Lic501 Details

A personnel record form is a document that stores information about an employee, such as their name, contact information, date of hire, and job title. This form can be used to track the progress of an employee within a company and document any disciplinary actions that have been taken against them. It is important for companies to keep accurate records on their employees in case there are any legal disputes or wrongful termination claims. A personnel record form template can make it easy for businesses to collect and store this information. When you're starting a new job, one of the first things you'll do is fill out some paperwork. This includes your Personnel Record Form.

In order to learn a few specific details relating to the PDF you're going to use, here's the facts you might want to study prior to completing the personnel record.

QuestionAnswer
Form NamePersonnel Record
Form Length2 pages
Fillable?Yes
Fillable fields160
Avg. time to fill out32 min 34 sec
Other namescdss lic 501, lic 501, lic 501 community care licensing, hcs 501 form

Form Preview Example

STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY

PERSONNEL RECORD

(Form to be completed by employee)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

DATE

NAME OF FACILITY

FACILITY ADDRESS

FACILITY FILE NUMBER

1.PERSONAL

NAME (LAST

FIRST

MIDDLE)

TELEPHONE

 

 

 

 

 

 

 

(

)

 

 

ADDRESS

 

 

 

 

 

 

ARE YOU 18 YEARS OF AGE OR OLDER?

 

 

 

 

 

 

 

YES

NO

IF NO, PLEASE STATE YOUR AGE

 

 

 

 

 

 

 

 

 

_____________________________

 

 

 

 

 

 

 

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? YES NO

IF YES, PLEASE LIST ALL NAMES USED.

 

 

 

 

 

 

 

 

 

 

 

DO YOU POSSESS A VALID CALIFORNIA DRIVER'S LICENSE?

YES NO

 

 

HAS YOUR DRIVER'S LICENSE EVER BEEN SUSPENDED OR REVOKED? YES NO

CDL NUMBER

 

 

 

 

 

IF YES, PLEASE EXPLAIN ON BACK OF FORM.

 

 

 

NEAREST LIVING RELATIVE — NAME:

 

 

 

 

 

 

TELEPHONE NUMBER

 

 

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.)

NAME AND ADDRESS OF EMPLOYER

TELEPHONE

NUMBER

JOB TITLE AND TYPE OF WORK

REASON FOR

LEAVING

DATES

FROM TO

4.EDUCATION

CIRCLE HIGHEST YEAR COMPLETED

6

7

8

9

10

11

12

DIPLOMA

CURRENTLY ENROLLED IN HIGH SCHOOL COMPLETION COURSE?

NO

YES IF YES, GIVE EXPECTED COMPLETION DATE___________________

EMPLOYMENT — RELATED EDUCATION COURSES

COURSE TITLE

NAME OF SCHOOL OR ORGANIZATION

AND ADDRESS

NUMBERDATE CURRENTLY UNITS

COMPLETED COMPLETED ENROLLED

LIC 501 (3/99)

(OVER)

4.EDUCATION (CONTINUED)

NAME UNIVERSITY, COLLEGE OR BUSINESS SCHOOL

AND ADDRESS

MAJOR

SUBJECT

NO. OF

NO. OF

DIPLOMA

 

YEARS

UNITS

DEGREE OR

DATE

COMPLETED

COMPLETED

CERTIFICATE

COMPLETED

 

 

 

 

5. REFERENCES

List names of three persons who can give information about your background, character, abilities, etc.

NAME

ADDRESS

TELEPHONE

NUMBER

RELATIONSHIP TO YOU

(FRIEND, EMPLOYER, ETC.)

6.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

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step 1 to writing  hcs 501 form

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