Department of Public Safety	COMMUNITY SERVICE ASSISTANTS TEL. NO. (818) 677-4997 9757 ZELZAH AVE, BLDG 14, STE. 101 NORTHRIDGE, CA     91330
	Matador Patrol Application Form

PLEASE RETURN COMPLETED FORM TO THE COMMUNITY SERVICE ASSISTANTS DIVISION OFFICE LOCATED AT 9757 ZELZAH AVE., BUILDING 14, SUITE 101. IF YOU HAVE ANY QUESTIONS, PLEASE CALL (818) 677-4997.

I. GENERAL INFORMATION:

First Name:		Last Name:	M.I.	Email Address:
Mailing Address:
Street:			P.O. Box:
City:			Phone:
Zip Code:			2nd Phone:
Home Address (If different from Mailing Address):
Street:			P.O. Box:
City:			Phone:
Zip Code:			2nd Phone:

Driver's License #:	State:	Exp. Date:
CSUN ID #:	Major:	Grad Date:
Are you a Work-Study student?	YES NO

II. EDUCATION:

CLASS STANDING:	Freshman	Sophomore	Junior	Senior	Grad Student
Current number of units enrolled:
List the names of any schools you have previously attended, starting with high school. Please include technical, military, and professional schools, as well as other colleges or universities.

Name:	City/State:	Dates:	Major:

III. SKILLS, EMPLOYMENT HISTORY & REFERENCES:

Check all boxes in which you are skilled:

ASL	CPR	Self-defense	EMT	First-Aid
Computer: IBM/MAC)		List Foreign Languages		Other
Please list "Other":

VI. NON-FAMILY REFERENCES:

Please list the names of three (3) non-family references:

	Name:	Relationship:	Phone #:
1.
2.
3.
Do you know anyone in the CSA Division or University Police? YES NO
If YES, enter their name:
Do you have any family members working in law enforcement?			YES NO
	Name:	Relationship:	Department:	Phone #:
1.
2.
3.

V. PERSONAL INFORMATION:

Have you ever been convicted of a crime as an adult and/or have you ever been arrested for a crime for which a trial is now pending? (Exclude traffic citations or other convictions that have been judicially dismissed, expunged, sealed, or eradicated? YES NO

If YES, please complete the information below:
1.	Describe the specific offense:
2.	If you were convicted, provide:
	Specific charge for which you were convicted:
	Date of conviction:
	Disposition (i.e. sentence):
3.	If trial is still pending, provide:
	Specific charge to be tried:
	Expected trial date:

VI. MEDICAL INFORMATION:

Do you require any medical assistance/aid? YES NO

If YES, please explain:

VII. SHIFT AVAILABILITY:
When are you available to start?
Can you work 15 to 20 hours per week, including midterms and finals?	YES NO
Are you able to work Friday and Saturday nights?	YES NO
Are you able to work between the hours of 5:00PM and 2:00AM?	YES NO
Are you able to work overnight Special Events?	YES NO
What are your goals after graduation?
Are you a member of any clubs or organizations? If YES, which one(s)?
How did you find out that the CSA was hiring?

VIII. ESSAY:

Please write and attach a brief essay describing your interests and goals in the Community Service Assistant Division and the reasons that you desire employment. (Use the back of this paper if necessary).

IX. EMPLOYMENT HISTORY:
List all previous employment for a minimum of three (3) years. Include military experience and relevant volunteer experience. List most recent employment first. Attach additional sheets, if necessary, with our name. A resume may be attached.
May we contact your present employer? YES NO	May we contact your previous employers? YES NO

1. Dates Worked: to	Supervisor's Name:
Name of Business:	Business Type:
City/State:	Phone:
Position Held:	Reason for Leaving:
Responsibilities:

2. Dates Worked: to	Supervisor's Name:
Name of Business:	Business Type:
City/State:	Phone:
Position Held:	Reason for Leaving:
Responsibilities:

3. Dates Worked: to	Supervisor's Name:
Name of Business:	Business Type:
City/State:	Phone:
Position Held:	Reason for Leaving:
Responsibilities:

4. Dates Worked: to	Supervisor's Name:
Name of Business:	Business Type:
City/State:	Phone:
Position Held:	Reason for Leaving:
Responsibilities:

I hereby verify that all statements made in this application are true and complete, and understand that any misstatement of the facts may subject me to disqualification or dismissal.
Signature: ________________________________________	Date: ____________