State of California Application
Instructions
Read the following instructions carefully before completing this application. Please complete the application on a computer or
print in ink. All questions must be answered completely and accurately, except as noted. You may be disqualied for any false
or misleading statements or for omitting information. The information you furnish will be used to apply for a job, determine your
eligibility and/or may be the basis for arriving at your nal rating in an examination. During the course of an examination, you may
be requested to provide additional information regarding your qualications, your preference regarding work location, shifts, etc.
Social Security Number (SSN) – Providing this is voluntary
in accordance with the Privacy Act of 1974 (PL 93-579).
However, a SSN may be needed to process your application
when granting items such as Veterans’ Preference, Limited
Examination and Appointment Program (LEAP), Career
Credits, and/or conrming list eligibility.
Examination(s) or Job Title(s) – Provide the title of the
position listed on the announcement.
Question 2 – Must be answered by all applicants. You must
answer “Yes” if you have ever, because of poor performance
or misconduct, been red, dismissed, or terminated from a job,
or had an employment contract terminated. Applicants who
have been rejected during a probationary period, or whose
dismissals or terminations have been overturned, withdrawn
(unilaterally or as part of a settlement agreement) or revoked
need not answer “Yes.” Explain any “Yes” answers in the
Explanations section. Briey describe the facts, ndings, any
action taken against you, and the circumstances under which
you left the position.
In completing this application, you do not need to answer “Yes”
to Question 2 if:
you have been rejected during a probationary period;
your employer withdrew the ring, dismissal, termination,
or contract termination (either voluntarily or as part of a
settlement); or
a court or administrative agency overturned or revoked the
ring, dismissal, termination, or contract termination.
If asked about past employment history by a prospective
employer during the hiring process or probationary period,
applicants are required to tell the truth regarding any ring,
dismissal, termination, contract termination or rejection during
probationary period, whether or not the action was overturned,
revoked, or withdrawn (either voluntarily by the employer or, as
part of a settlement agreement). Applicants are also required
to provide factually correct information in the Employment
History section of the application.
Question 3 – Must be answered by all applicants. Government
Code section 18720.45 requires applicants for state
employment to disclose on their application form whether they
have entered into any agreement(s) with the state in which
the applicant agreed to refrain from seeking or accepting any
subsequent employment with the state. You must answer
“Yes” to this question if you have ever entered into a written
agreement with any department, agency, commission, board,
state employer, or other governmental unit within California
state civil service, where one of the terms of the agreement
provided that you agreed not to seek or accept subsequent
employment with the state or any state agency. A state agency
includes any department, agency, commission, board, state
employer, or other governmental unit within the California
state civil service, but does not include the California State
University.
Question 4 – Must be answered by all applicants.
Government Code section 18720.45 requires applicants for
state employment to disclose on their application form whether
they have entered into any agreement(s) with the state in
which the applicant agreed to refrain from seeking or accepting
any subsequent employment with the state. You must answer
“yes” to this question if you have ever entered into a written
agreement with any department, agency, commission, board,
state employer, or other governmental unit within the California
state civil service, involving an adverse action, rejection on
probation, or AWOL termination where one of the terms of the
agreement provided that you agreed not to seek or accept
subsequent employment with a particular state agency. A
state agency includes any department, agency, commission,
board, state employer, or other governmental unit within the
California state civil service, but does not include the California
State University. If you answer “Yes” to this question, please
provide the name of the particular agency and the details in the
Explanations section.
Question 10 – If you checked “Yes” and you are not able to
attach the Accommodation Request form, you will be contacted
via telephone or mail to make specic arrangements.
Explanations – Use this section to explain the details of any
response that requires additional information. Be thorough,
and attach additional sheet(s) if needed.
Applicant’s Signature – Your signature and the date signed
is required. If the hard copy application is not signed, it may
be rejected. Electronic submission of your application through
a CalCareer Account certies your application in place of a
signature and date signed.
Education – You must include a complete record of your
training and educational background. Please read the
requirements of the examination bulletin for any specic
educational requirements. If more space is needed, you may
attach additional documentation.
STATE OF CALIFORNIA - CALIFORNIA DEPARTMENT OF HUMAN RESOURCES
EXAMINATION / EMPLOYMENT APPLICATION
STD. 678 (REV. 06/2024) Page 1
Preference Form, CALHR-1093 to the California Department of
Human Resources.
Equal Employment Opportunity Page – Providing this
information is voluntary. This data is only to be used for
statistical purposes in evaluating the extent to which the
state is complying with state and federal equal employment
opportunity and non-discrimination requirements.
NOTE: Your completed application and other examination
related information submitted to the department administering
this examination becomes condential information and the
property of the State of California as provided by Government
Code section 18934. This application and other condential
information will not be returned; therefore, it is recommended
that you keep a copy of your completed application for your
records. Your rights to inspect your examination papers are
set forth in Title 2, section 186 -189 of the California Code of
Regulations, which can be accessed at Oce of Administrative
Law website at: oal.ca.gov.
STATE OF CALIFORNIA - CALIFORNIA DEPARTMENT OF HUMAN RESOURCES
EXAMINATION / EMPLOYMENT APPLICATION
STD. 678 (REV. 06/2024) Page 2
Licenses – If the examination bulletin requires a specic
license, professional certicate, or membership in a
professional organization, list the full name of the license,
certicate or organization, the license number, and the ocial
expiration date of the document or membership.
Employment History and Experience – You must include a
complete list of your paid and/or volunteer work experience
that relates to the qualication requirements specied
on the examination bulletin. List all relevant jobs during the
past 10 years, regardless of duration, including part-time and
military service. You should also list volunteer experience and
jobs if they directly relate to the job for which you are applying.
State employees must list the specic departments for
which they worked and indicate the specic civil service
class title(s) held.
Requesting Veterans’ Preference – If you have not
previously applied and been approved for Veterans’
Preference, you must complete and submit the Veterans’
Physical disability includes but is not limited to having any physiological disease, disorder, condition, cosmetic disgurement, or
anatomical loss that aects one or more of several body systems and limits a major life activity. The body systems listed include
the neurological, immunological, musculoskeletal, special sense organs, respiratory, including speech organs, cardiovascular,
reproductive, digestive, genitourinary, hemic and lymphatic, skin, and endocrine systems. A physiological disease, disorder,
condition, cosmetic disgurement, or anatomical loss limits a major life activity, such as working, if it makes the achievement of the
major life activity dicult.
Mental disability includes but is not limited to having any mental or psychological disorder or condition, such as intellectual or
cognitive disability, organic brain syndrome, emotional or mental illness, or specic learning disabilities, that limits a major life
activity, or having any other mental or psychological disorder or condition that requires special education or related services.
Major life activities are dened broadly and include physical, mental, and social activities, including but not limited to, caring for
oneself, performing manual tasks, seeing, hearing, eating, sleeping, walking, standing, sitting, reaching, lifting, bending, speaking,
breathing, learning, reading, concentrating, thinking, communicating, interacting with others, and working. Major life activities
include the operation of major bodily functions, including functions of the immune system, special sense organs and skin, normal
cell growth, digestive, genitourinary, bowel, bladder, neurological, brain, respiratory, circulatory, cardiovascular, endocrine, hemic,
lymphatic, musculoskeletal, and reproductive functions.
Major bodily functions include the operation of an individual organ within a body system.
An impairment “limits” a major life activity if it makes the achievement of the major life activity dicult.
Medical condition is dened as any health impairment related to or associated with a diagnosis of cancer or a record or history of
cancer, or a genetic characteristic.
Genetic characteristic is dened as any scientically or medically identiable gene or chromosome or an inherited characteristic
that could statistically lead to increased development of a disease or disorder.
California Code of Regulations, Title 2, section 11065.
Information About Disability
Applications will ONLY be processed for active recruitment
eorts - see exam bulletin or job posting.
PRINT OR TYPE
APPLICANT’S NAME (Last) (First) (M.I.) CALCAREER ID
MAILING ADDRESS (Number) (Street) (Apt #) SOCIAL SECURITY NUMBER (Exams Only)
(City) (County) (State) (Zip Code)
EXAMINATION(S) OR JOB TITLE(S) FOR WHICH YOU ARE APPLYING
E-MAIL ADDRESS 1st TELEPHONE NUMBER 2nd TELEPHONE NUMBER
STANDARD EMPLOYMENT QUESTIONS
PERSONNEL
USE ONLY
Work
Home
Other
Work
Home
Other
STATE OF CALIFORNIA - CALIFORNIA DEPARTMENT OF HUMAN RESOURCES
EXAMINATION / EMPLOYMENT APPLICATION
STD. 678 (REV. 06/2024) Page 3
1. Are you now employed by the State of California? If “Yes,” ll in the information below.
Department: Subdivision:
2. Have you ever been red, dismissed, terminated, or had an employment contract terminated from any position for
performance or for disciplinary reasons? If “Yes,” give details in the “Explanation” section below and refer to the
instructions page for further information.
3. Have you ever entered into any written agreement with a state agency in which you agreed not to seek or accept
subsequent employment with the state or any state agency?
4. Have you ever entered into any written agreement with a state agency involving an adverse action, rejection on probation,
or AWOL termination, in which you agreed not to seek or accept subsequent employment with a particular state agency?
5. In addition to English, list any other languages you are uent in:
Yes
No
Yes
No
Yes
No
Yes
No
a. Verbal uency in
b. Written uency in
6. For typing applicants only: I certify I can type at a speed of words per minute.
ANSWER THE FOLLOWING QUESTIONS IF APPLYING TO TAKE AN EXAMINATION
7. Do you meet the minimum and/or maximum age requirements?
8. Do you possess a valid California Driver License? If “Yes,” ll in the information below.
Yes
No
Yes
No
I certify under penalty of perjury that the information I have entered on this application is true and complete to the best of my knowledge.
I further understand that any false, incomplete, or incorrect statements may result in my disqualication from the examination process or
dismissal from employment with the State of California. I authorize the employers and educational institutions identied on this application to
release any information they may have concerning my employment or education to the State of California.
CERTIFICATION – IMPORTANT – READ BEFORE SIGNING – YOUR SIGNATURE IS REQUIRED FOR HARD COPY SUBMISSION
License #: Class: Restrictions:
APPLICANT’S SIGNATURE DATE SIGNED
EXPLANATIONS: Provide details of any response that requires additional information.
NOTE: If you are a veteran, widow or widower of a veteran, or spouse of a 100% disabled veteran, you may qualify for Veterans’ Preference. For information
regarding Veterans’ Preference see www.calcareers.ca.gov or www.calvet.ca.gov.
APPLICANTS — DO NOT USE THE SPACE BELOW — FOR PERSONNEL USE ONLY
FOR PERSONNEL USE ONLY
EXPERIENCE
EDUCATION
STAFF DATE PROCESSED
OTHER
LICENSE REQUIREMENT
STATUS
Accepted REJECTED WC
Classes
01 02 03 04 05 06
WC for
Series/Levels
RC/Flag for
Series/Levels
CODES
Flags
WC
State of California Application
9. Enter your preferred county to take the examination, if dierent from your county of residence:
10. Do you need an accommodation to take an examination or assessment? If “Yes,” complete the Accommodation form.
Yes
No
ANSWER THE FOLLOWING QUESTIONS ONLY IF THE EXAM BULLETIN OR JOB POSTING REQUIRES THE INFORMATION
Print
Clear
Save
STATE OF CALIFORNIA - CALIFORNIA DEPARTMENT OF HUMAN RESOURCES
EXAMINATION / EMPLOYMENT APPLICATION
STD. 678 (REV. 06/2024) Page 4
UNIVERSITY OR COLLEGE — BUSINESS, CORRESPONDENCE,
TRADE OR SERVICE SCHOOL, NAME AND LOCATION
COURSE OF STUDY
UNITS
COMPLETED
SEMESTER
UNITS
COMPLETED
QUARTER
DIPLOMA, DEGREE OR
CERTIFICATE OBTAINED
DATE
COMPLETED
EDUCATION
LICENSES – LIST APPLICABLE LICENSES AND CERTIFICATES INDICATED IN THE EXAMINATION BULLETIN.
(If you are an attorney, please indicate the date you were admitted to the Bar under the Issue Date column, if stated on the examination bulletin.)
DID YOU GRADUATE FROM HIGH SCHOOL? IF NOT, DO YOU POSSESS A GED OR EQUIVALENT? IF NOT, ENTER THE HIGHEST GRADE YOU COMPLETED?
Yes No Yes No
LICENSE / CERTIFICATION NUMBER ISSUE DATE EXPIRATION DATE
IN THE SPACE BELOW, INDICATE SPECIFIC COURSE REQUIREMENTS NEEDED
TO SATISFY REQUIREMENTS FOR THIS EXAMINATION
EMPLOYMENT HISTORY – List relevant paid, military and/or volunteer experience that relate to the qualication requirements. List each job separately.
APPLICANT’S NAME (Last) (First) (M.I.) CALCAREER ID
FROM (MM/DD/YY) TO (MM/DD/YY) TITLE/JOB CLASSIFICATION (Include Range or Level, if applicable) SUPERVISOR NAME
HOURS PER WEEK COMPANY/STATE AGENCY NAME SUPERVISOR PHONE NUMBER
ADDRESS
DUTIES PERFORMED
REASON FOR LEAVING
TOTAL WORKED
STATE OF CALIFORNIA - CALIFORNIA DEPARTMENT OF HUMAN RESOURCES
EXAMINATION / EMPLOYMENT APPLICATION
STD. 678 (REV. 06/2024) Page 5
APPLICANT’S NAME (Last) (First) (M.I.) CALCAREER ID
FROM (MM/DD/YY) TO (MM/DD/YY) TITLE/JOB CLASSIFICATION (Include Range or Level, if applicable) SUPERVISOR NAME
HOURS PER WEEK COMPANY/STATE AGENCY NAME SUPERVISOR PHONE NUMBER
ADDRESS
DUTIES PERFORMED
REASON FOR LEAVING
TOTAL WORKED
SUPERVISOR NAME
SUPERVISOR PHONE NUMBER
FROM (MM/DD/YY) TO (MM/DD/YY) TITLE/JOB CLASSIFICATION (Include Range or Level, if applicable)
HOURS PER WEEK COMPANY/STATE AGENCY NAME
ADDRESS
DUTIES PERFORMED
REASON FOR LEAVING
TOTAL WORKED
STATE OF CALIFORNIA - CALIFORNIA DEPARTMENT OF HUMAN RESOURCES
EXAMINATION / EMPLOYMENT APPLICATION
STD. 678 (REV. 06/2024) Page 6
APPLICANT’S NAME (Last) (First) (M.I.) CALCAREER ID
FROM (MM/DD/YY) TO (MM/DD/YY) TITLE/JOB CLASSIFICATION (Include Range or Level, if applicable) SUPERVISOR NAME
HOURS PER WEEK COMPANY/STATE AGENCY NAME SUPERVISOR PHONE NUMBER
ADDRESS
DUTIES PERFORMED
REASON FOR LEAVING
TOTAL WORKED
FROM (MM/DD/YY) TO (MM/DD/YY) TITLE/JOB CLASSIFICATION (Include Range or Level, if applicable) SUPERVISOR NAME
HOURS PER WEEK COMPANY/STATE AGENCY NAME SUPERVISOR PHONE NUMBER
ADDRESS
DUTIES PERFORMED
REASON FOR LEAVING
TOTAL WORKED
STATE OF CALIFORNIA - CALIFORNIA DEPARTMENT OF HUMAN RESOURCES
EXAMINATION / EMPLOYMENT APPLICATION
STD. 678 (REV. 06/2024) Page 7
APPLICANT’S NAME (Last) (First) (M.I.) CALCAREER ID
FROM (MM/DD/YY) TO (MM/DD/YY) TITLE/JOB CLASSIFICATION (Include Range or Level, if applicable) SUPERVISOR NAME
HOURS PER WEEK COMPANY/STATE AGENCY NAME SUPERVISOR PHONE NUMBER
ADDRESS
DUTIES PERFORMED
REASON FOR LEAVING
TOTAL WORKED
FROM (MM/DD/YY) TO (MM/DD/YY) TITLE/JOB CLASSIFICATION (Include Range or Level, if applicable) SUPERVISOR NAME
HOURS PER WEEK COMPANY/STATE AGENCY NAME SUPERVISOR PHONE NUMBER
ADDRESS
DUTIES PERFORMED
REASON FOR LEAVING
TOTAL WORKED
STATE OF CALIFORNIA - CALIFORNIA DEPARTMENT OF HUMAN RESOURCES
EXAMINATION / EMPLOYMENT APPLICATION
STD. 678 (REV. 06/2024) Page 8
APPLICANT’S NAME (Last) (First) (M.I.) CALCAREER ID
FROM (MM/DD/YY) TO (MM/DD/YY) TITLE/JOB CLASSIFICATION (Include Range or Level, if applicable) SUPERVISOR NAME
HOURS PER WEEK COMPANY/STATE AGENCY NAME SUPERVISOR PHONE NUMBER
ADDRESS
DUTIES PERFORMED
REASON FOR LEAVING
TOTAL WORKED
FROM (MM/DD/YY) TO (MM/DD/YY) TITLE/JOB CLASSIFICATION (Include Range or Level, if applicable) SUPERVISOR NAME
HOURS PER WEEK COMPANY/STATE AGENCY NAME SUPERVISOR PHONE NUMBER
ADDRESS
DUTIES PERFORMED
REASON FOR LEAVING
TOTAL WORKED
STATE OF CALIFORNIA - CALIFORNIA DEPARTMENT OF HUMAN RESOURCES
EXAMINATION / EMPLOYMENT APPLICATION
STD. 678 (REV. 06/2024) Page 9
The California Department of Human Resources (CalHR) is committed to the privacy of your personal information. The information
requested on this form may include personal information. Under the Information Practice Act of 1977, California Civil Code
section 1798.17, agencies/departments that use this form to collect personal information from individuals are required to provide a
privacy notice with this form. For more information, you may wish to contact the appointing authority at which you are applying to
receive information regarding that appointing authority's privacy policy, and privacy notice on information collection.
Legal Authority for Collection and Use of Information
CalHR is requesting the information specied on this form pursuant to Government Code sections 8310.5, 11019.11, 12946,
18720, 18720.1, 19233, 19234, 19705, 19790, 19792(h) and the California Code of Regulations, Title 2, sections 599.980,
11013(b).
The information collected will be used for scheduling examinations, determining your eligibility for state civil service, and
contacting you. Information will also be used for statistical and analytic purposes, audit purposes and may be disclosed to the
appointing authority to which you apply.
Individuals should not provide personal information that is not requested or required.
The submission of all information requested is mandatory unless otherwise noted. If you fail to provide the information requested,
CalHR will not be able to determine your eligibility for state civil service employment.
Disclosure and Sharing
CalHR does not, under any circumstance, sell your electronically collected personal information. In addition, Government Code
section 11015.5 (6) prohibits CalHR and all state agencies from distributing or selling any electronically collected personal
information, as dened above, about users to any third party without the written permission of the user. Any distribution of
electronically collected personal information will be used solely for its intended use. However, we may share your personal
information under the following circumstances:
1. To other state departments and third party vendors for administering our human resource responsibilities as required by
law;
2. You give us permission and we have your consent; and/or
3. We may release information to a party with a legal authority, such as a subpoena.
Department Privacy Policy
The information collected by CalHR is subject to the limitations in the Information Practices Act of 1977 and state policy. For more
information on how we care for your personal information, please read our Privacy Policy at http://calhr.ca.gov/pages/privacy-
policy.aspx.
Access to Your Information
You can view your personal information through your CalCareer account. If you have questions regarding your CalCareer
account, you may contact the CalHR Selection Division.
CalHR Selection Division
1515 S Street, Room, 500N
Sacramento, CA 95811
866-844-8671
CalHR Privacy Notice on Information Collection
RACE AND ETHNICITY
Check one or more boxes that best describe your race or ethnicity.
DISABILITY
A person with a disability is an individual who:
• has a physical or mental impairment or medical condition that limits one or more life activities, such as walking,
speaking, breathing, performing manual tasks, seeing, hearing, learning, caring for oneself or working;
• has a record or history of such impairment or medical condition; or
• is regarded as having such an impairment or medical condition.
Please refer to the instructions for more information regarding how disability is dened under the law.
MILITARY
Have you ever served in the United States military? Please check the appropriate box below.
AUTHORITIES
Government Code sections 8310.5, 11019.11, 12946, 19233, 19234, 19705, 19790, 19792(h) and California Code of
Regulations, Title 2, sections 599.980, 11013(b) authorize the State of California to collect demographic information on
job applicants and exam participants for analysis and statistical purposes.
STATE OF CALIFORNIA - CALIFORNIA DEPARTMENT OF HUMAN RESOURCES
EXAMINATION / EMPLOYMENT APPLICATION
STD. 678 (REV. 06/2024) Page 10
EQUAL EMPLOYMENT OPPORTUNITY
APPLICANT: This data assists the State of California in its commitment to equal employment opportunity. Applicants are asked
to voluntarily provide the information below. This questionnaire will be separated from the application and will not be used in
any employment decisions. This data will be used for statistical data gathering and reporting purposes in evaluating the extent
to which the state is complying with state and federal equal employment opportunity and non-discrimination requirements.
ASIAN PACIFIC ISLANDER
Guamanian
(R)
Hawaiian (P)
Samoan (Q)
Other Pacic Islander (T)
Indian (M)
Cambodian (U)
Chinese (J)
Filipino (G)
Japanese (I)
Korean (K)
Laotian (V)
Vietnamese (L)
Other Asian (S)
Thank You For Completing This Questionnaire
Yes, I have served in the military No, I have not served in the military
Yes, I have a disability No, I do not have a disability
BLACK or AFRICAN AMERICAN
(F)
AMERICAN INDIAN or ALASKA
NATIVE (H)
HISPANIC or LATINO (D)
WHITE (E)
SOCIAL SECURITY NUMBER AGE GENDER
Male FemaleUnder 21
(1) 21-39 (3)
40-69 (6) 70 and Over (7)
I choose not to identify.
A descendant of a person or persons
who were enslaved in the United States.
Unknown
Not a descendent of a person or persons
who were enslaved in the United States,
including, but not limited to, African
Black, Caribbean Black, or other Black.
Non-binary
LGBTQ+
Do you identify as LGBTQ+?
Yes No
