1. EMPLOYEE:

Please type or print neatly making sure all information is legible and provided as omissions will delay processing. Please print or type and ensure all information is provided as omissions can delay processing.

First name:

Last name:

Middle Name

Suffix

DOB

Title of Position Applied For:

2. Gender:

Female/Male

SELF-DISCLOSURE AS AN INDIVIDUAL WITH A DISABILITY MENTAL OF PHYSICAL

Federal and State law and District policy require that new employees be given the opportunity to identify themselves as an individual with a disability, mentally or physically. Do you identify as an individual with a disability? Yes/No

SELF-DISCLOSURE OF VETERAN/DISABLED VETERAN STATUS

Federal and State law and District policy require that new employees be given the opportunity to identify themselves as veteran, or disabled veteran. If applicable, type one only:

Vietnam era veteran,
Disabled Veteran,
Other than Vietnam era,
Disabled Vietnam era veteran,
Not disabled Veteran,
Other than Vietnam era,
Not disabled,
Not a veteran

Pick one State:

  California
  Nevada
  Texas
  Ohio
  Kansas
  Florida
  New York
  Colorado
  Washington
  Idaho
  Oregon
  New Mexico
  Utah

Choose Only One Position (if applicable):

  Mathematics
  HTML
  CSS
  Javascript
  Linux Command
  Node.js
  Cartography

Choose Only One Position:

  State Delegate Representative
  District Coordinator Representative
  District Advisor Representative
  Field Coordinator Representative
  Field Advisor Representative
  Canvasser Representative
  Data Specialist
  Database Specialist
  Website Developer
  Website Designer

Assignments are limited to 180 day length of service at any one time and may or may not be renewed depending upon the needs of the District. Your assignment must be approved by the District Office before you may start working. Your assignment must be approved by the C.E.O. of B.L.A.C.C. Corporation before you may start working. Employment in the Unclassified Service is “at will” which means it can be terminated at any time for any reason or no reason at all. Although the planned period of your employment is indicated by the dates of your assignment, such employment may be terminated at any time. Positions in the Unclassified Service do not have a continuing right of employment. I have read, understand, and agree to the terms of Unclassified Service employment and certify any information I have provided is true and correct.
In regards to B.L.A.C.C. CORPORATION, I,

will adhere to all rules and guidelines due to the position I occupy within B.L.A.C.C. Connect. I,

, promise to follow and adhere to all rules and guidelines to the best of my knowledge and experience. The following rules and guidelines below, I,

will not violate; if during occupying the position in B.L.A.C.C. Connect, I,

,violates the rules and guidelines, I,

will resign. The following are the rules and guidelines for confidentiality within B.L.A.C.C. CORPORATION:


1. No sharing information about State Delegate, District Coordinator, District Advisor,
Field Coordinator, Field Advisor, Canvasser, Data Specialist, Database Specialist, Website
Developer, Website Designer, clients, investors or board members with anyone outside
the board, without proper permission from the respective B.L.A.C.C. Connect State Delegate.

2. No sharing business information in regards to B.L.A.C.C. CORPORATION financial
and business status. Unless proper forms are provided.


3. No sharing information on the developmental status of B.L.A.C.C. Connect within and
outside of B.L.A.C.C. CORPORATION.


4. Personal password/username must not be shared with anyone.
By signing the confidentiality Agreement,

I,

agree to all statements, propositions, rules and guidelines depicted above.

First name:

Last name:

Middle Name

Suffix

Social Security No.

Location

2. CONVICTIONS:

Have you ever been convicted?

Yes, complete the required information below. INSTRUCTIONS In the spaces below, give complete details for every time you have been convicted as an adult (fined, imprisoned, placed on probation, given a suspended sentence, or have forfeited bail) in connection with any offence, in civilian or military life. If you submit incomplete information, it will delay the processing of employment.

Message:


If you use penal code numbers, note that use of incorrect codes will delay the processing of
your application.

If you are in doubt, list your conviction and explain.

If available, you may attach copies of court documents that identify the specific conviction.
Do not include any conviction specified in Labor Code 432.8, which refers to various marijuana
related offenses that are more than two years old.

Do not include minor traffic violations such as parking or speeding unless you were convicted for
failure to appear for fine or sentencing.

Do not include arrests which resulted in Diversion unless you were convicted for failure to meet
the conditions of your program.

Do not include arrests that did not result in convictions, charges that have been dismissed,
sealed, expunged, or juvenile records.

You will be fingerprinted for processing through the criminal records system. If you fail to disclose a criminal conviction or provide inaccurate information, you could forfeit employment consideration.

Date of Conviction (only numbers):

City/ State

Disposition

Length of Time Served

Law or Code Violation

Name of Institution Where Time Was Served

(Optional) If necessary, use additional sheets of paper: sign and date the bottom of each additional page. Failure to account for all applicable convictions may disqualify you from employment with the District, or if already employed, may cause you to be dismissed from employment. I certify that this Report of Convictions is true to the best of my knowledge and belief.

Mandated Reporter Responsibilities Under The Child Abuse And Neglect Reporting Act.

Reportable Types of Abuse and Neglect The following condition must be reported under CNRA: Sexual abuse (including sexual assault, sexual exploitation, pornography, and child prostitution);, general or server neglect ; physical abuse (including crreult ior unjustifiab le punihment, unlawful corporal punishment or injury and non-accidental physical injury ; and/or neglect in out-of-home care. Who Reports Mandated Reporters include the following individuals: teachers, instructional aides; teacher’s aide; instructional assistants; classified employees of any public school; administrators or employees of licensed community care or child day care family centers. Who Do You Report To Mandated Reporters are required report all incidents that pretain to the Child Abuse and Neglect Reporting Act to the State Delegate of the respective State of B.L.A.C.C. Connect. Also a report will be sent to the CEO of B.L.A.C.C. Corporation. Type name below if you understand your responsiblity on behalf of B.L.A.C.C. Corporation.
First Name:

Last Name:

Middle Name

Suffix

Social Security No.

Location

1. EMPLOYEE OFFICIAL ADDRESS May be a District location or PO Box.

Street Address

Unit No.

City

State

Zip Code

Daytime Phone

Evening Phone

Cell Phone

Email

A. RESTRICTIONS ON RELEASE OF ADDRESS / TELEPHONE Check this box if you do not wish to have your address and telephone number released to anyone except the organization designated as the exclusive representative for the employee unit to which you are assigned. B. UNEMPLOYMENT INSURANCE CLAIMS Check this box if you wish your exclusive representative to receive your name in the event you file for unemployment insurance benefits.

2. SALARY WARRANT / DIRECT DEPOSIT ADVISE ADDRESS:

Direct Deposit / Complete B.L.A.C.C. Direct Deposit Authorization Card (Obtain from the Secretary of B.L.A.C.C. Corporation)

Mail to my official address listed above.

Mail to the address listed below. (PO Box may be used here.)

Mailing Address

Street Address

City

State

Zip Code

WARRANT RECIPIENT DESIGNATION

As provided in California Government Code § 53245, in the event of my death, I hereby designate the following person to receive any an all warrants payable to me by B.L.A.C.C. Corporation. This designation will remain in effect until canceled and replaced in writing. It is also expressly understood and agreed that B.L.A.C.C. Corporation is not obligated to deliver said warrants to the person designated above unless the designated person, within two years after the date of said warrant or warrants, claims such warrants from the B.L.A.C.C. Corporation and provides the District with sufficient proof of identify.

First Name

Last Name

Relationship

Street Address

City

State

Zip Code

Daytime Phone

NAME

OFFICE OF EMPLOYER EMPLOYEE RELATIONS USE ONLY

Clear
Do not clear
Reviewed
Recommended by
Date:


____________________________________________________________________________________________________
Signature 									Date

B.L.A.C.C. Connect Application

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