Medical Consultant I And Or Medical Consultant I (Page 4 of 4) in pdf

Medical Consultant I And Or Medical Consultant I Page 4

Candidate’s Name:

Address:

Phone Number:

E-mail:

Medical License:

Number

Expiration Date

State

Specialty Board Certification:

Number

Specialty

Expiration Date

Board Re-certification date:

CONDITIONS OF EMPLOYMENT

If you are successful in the exam, your name will be placed on the active employment list and

certified to fill vacancies according to the locations(s) you specify.

______ COVINA

______ ROSEVILLE

______ FRESNO

______ SACRAMENTO

______ LOS ANGELES

______ SAN DIEGO

______ OAKLAND

______ STOCKTON

I certify that all the statements I have made in this application are true and correct.

Signature

Date

MAILING INSTRUCTIONS:

Mail your completed Supplemental Application along with a standard State Application Form, STD.678 to the address

listed below. You may print the State Application from the State Personnel Board’s website at

MAIL COMPLETED STD. 678 AND SUPPLEMENTAL APPLICATION TO:

California Department of Social Services

P.O. Box 944243 MS 8-15-59

Sacramento, CA 94244-2430

CRIMINAL RECORD CLEARANCE INFORMATION: Some positions, within various divisions of the California

Department of Social Services, are subject to fingerprinting and criminal records check requirements. This check will be

completed by the Department of Justice. Applicants will be notified during the hiring process if the position is affected by

the criminal records clearance procedure. Criminal record clearance is a condition of employment in positions affected by

this procedure.

Medical Consultant I And Or Medical Consultant I Page 4