Emt-Basic/CNA
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STATE OF CALIFORNIA STATE PERSONNEL BOARD
Applications will be processed ONLY for classifications where an
examination is in progress and the published final filing date has not passed,
EXAMINATION/EMPLOYMENT APPLICATION
or for vacant positions where a department requests an application.
STD. 678 (REV. 6/2010) Page 1
PRINT OR TYPE PLEASE SEE INSTRUCTIONS ON BACK PAGE
APPLICANT IDENTIFICATION NUMBER (EASY ID) EASY ID
FIRST 3 LETTERS OF LAST 4 DIGITS OF SOCIAL
0 2
DUP 1 4 8 1 8 0
DAY OF BIRTH
MONTH OF BIRTH DUP02148180
LAST NAME AT BIRTH SECURITY NUMBER
(First) (M.I.) SOCIAL SECURITY NUMBER
APPLICANT'S NAME (Last)
B. ***-**-****
duPlantier Rory
MAILING ADDRESS (Number) E-MAIL ADDRESS WORK TELEPHONE NUMBER
(Street)
5571 Airdrome St. ***********@**********.*** 323-***-****
(City) (County) (State) (Zip Code) HOME/VRS/TTY TELEPHONE NUMBER
Los Angeles Los Angeles CA 90019-3803
EXAMINATION(S) OR JOB TITLE(S) FOR WHICH YOU ARE APPLYING PERSONNEL
USE ONLY
PSYCHIATRIC TECHNICIAN ASSISTANT (SAFETY)
ANSWER THE FOLLOWING QUESTIONS:
1. Enter the county in which you would like to take the
examination if different from the county of your residence:
2. Do you need reasonable accommodation to take an interview or written test? NO
YES
3. Do your religious beliefs prevent you from taking an examination on Saturday? NO
YES
Are you now employed by the State of California? (If "YES", fill in the information below.)
4. NO
YES
Department: Subdivision:
Have you ever been fired, dismissed, terminated, or had an employment contract terminated from any position for
5. NO
YES
performance or for disciplinary reasons? (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dismissals or terminations have been overturned, withdrawn [unilaterally or as part of a settlement agreement] or revoked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".) Refer to the Instructions for further information. If "Yes" to Question #5, give details in the
Explanations section.
6. In addition to English, list any other languages you:
a. possess verbal fluency in
b. possess written fluency in
7. I certify I can type at a speed of words per minute. (For typing applicants only.)
(ANSWER QUESTIONS 8 AND 9 ONLY IF THE EXAMINATION INDICATES THEY ARE REQUIRED.)
8. Do you meet the minimum and/or maximum age requirements? NO
YES
9. NO
YES
Do you possess a valid California Driver License? (If "YES", fill in the information below.)
License# N7627863 Class: CM1 Restrictions: CORR LENS
EXPLANATIONS
CERTIFICATION – IMPORTANT – PLEASE READ BEFORE SIGNING – If not signed, this application may be rejected.
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 disqualification from the examination process or dismissal from employment with the
State of California. I authorize the employers and educational institutions identified on this application to release any information they may have concerning
my employment or education to the State of California.
DATE SIGNED
APPLICANT'S SIGNATURE
APPLICANTS DO NOT USE THE SPACE BELOW FOR PERSONNEL USE ONLY
03 05
Classes 01 02 04 06 FOR PERSONNEL USE ONLY
Flags
STATUS
WC for
WC
Series/Levels
ACCEPTED REJECTED WC
RC/Flag for
EXPERIENCE LICENSE REQUIREMENT
Series/Levels
CODES EDUCATION OTHER
STAFF DATE PROCESSED
STATE OF CALIFORNIA STATE PERSONNEL BOARD
EXAMINATION/EMPLOYMENT APPLICATION
STD. 678 (REV. 6/2010) Page 2
(First) (M.I.) EASY ID
APPLICANT'S NAME (Last)
duPlantier Rory B. DUP02148180
EDUCATION
DID YOU GRADUATE FROM HIGH SCHOOL? IF NOT, DO YOU POSSESS A GED OR EQUIVALENT? IF NOT, ENTER THE HIGHEST GRADE YOU COMPLETED
NO YES
YES NO
UNIVERSITY OR COLLEGE NAME AND LOCATION,
DIPLOMA, DEGREE OR DATE
UNITS COMPLETED
COURSE OF STUDY
BUSINESS, CORRESPONDENCE, TRADE OR
CERTIFICATE OBTAINED COMPLETED
SERVICE SCHOOL QUARTER
SEMESTER
American Red Cross 1450 11th St. SM,CA Nurse Assistant CA Dept.Public Health Certified 12/06/2011
90401 310-***-**** Nurse Assistant License
Los Angeles City College 855 N.Vermont Medical Vocabulary Medical Terminology I/II 08/06/2011
LA,CA 90029 323-***-****
North Valley Occupational Ctr. 111450 Sharp EMT-1 EMT Basic License 07/01/1991
av. MH,CA 91345 818-***-****
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.)
EXPIRATION IN THE SPACE BELOW, INDICATE SPECIFIC COURSE REQUIREMENTS NEEDED
LICENSE/CERTIFICATION NUMBER ISSUE DATE
DATE TO SATISFY REQUIREMENTS FOR THIS EXAMINATION
00834403 CNA 02/23/2013 02/14/2015 CNA / Advanced CPR
AHA Healthcare Provider CPR/AED 05/05/2013 05/2015
EMPLOYMENT HISTORY– Begin with your most recent job. List each job separately.
TO (MM/DD/YY) TITLE/JOB CLASSIFICATION (Include Range or Level, if applicable) SUPERVISOR NAME
FROM (MM/DD/YY)
01/18/2008 07/01/2011 Emergency Medical Technician/Field Training Officer Emp#719A Ramona Roberts
HOURS PER WEEK COMPANY/STATE AGENCY NAME SUPERVISOR PHONE NUMBER
TOTAL WORKED (Years/Months)
45+ 3yrs 6mo. Trans Aid Ambulance Service 562-***-****
ADDRESS
SALARY EARNED
1300 Gardena av. Glendale,CA 91204
hour
$ 14.50 PER
DUTIES PERFORMED
EMT field training of new hire EMT's in LA County EMS protocol.Emergent and non emergent triage,treatment and transport of the sick and
injured.Vital sign trending,BLS intervention,comprehensive medical documentation of all procedures.Mental health transport's from psychiatric
ER's,transitional living and board/care facilities.Jail custody,homeless outreach transport's.Psychiatric Mobile Response Team for involuntary
detention of mentally disordered adults and children.Restraint application with distal limb neurovascular monitoring every fifteen
minutes.Patient positioning,Intake/Output charting,oxygen administration,airway suctioning PRN.
REASON FOR LEAVING
Company Bankruptcy
FROM (MM/DD/YY) TO (MM/DD/YY) TITLE/JOB CLASSIFICATION (Include Range or Level, if applicable) SUPERVISOR NAME
06/01/2007 12/15/2007 EMT Attendant/Driver Emp#1442 Pedro Flores
COMPANY/STATE AGENCY NAME
HOURS PER WEEK SUPERVISOR PHONE NUMBER
TOTAL WORKED (Years/Months)
45+ 6 months Bower's Ambulance DBA Rural/Metro 866-***-****
SALARY EARNED ADDRESS
$ 11.00 hour 3355 E.Spring St. #301 Long Beach,CA 90806
PER
DUTIES PERFORMED
Emergent and non emergent triage,treatment and transport of the sick and injured.Vital sign trending,BLS intervention,comprehensive medical
documentation of all procedures.Expanded EMT scope utilization,inventory/refill of medical supplies.Mental health voluntary/involuntary
transport's from psychiatric ER's to BHU or high risk unit's.LAPD Systemwide Mental Assessment Response Team calls.
REASON FOR LEAVING
Reduced hours
STATE OF CALIFORNIA STATE PERSONNEL BOARD
EXAMINATION/EMPLOYMENT APPLICATION
STD. 678 (REV. 6/2010) Page 3
(First) (M.I.) EASY ID
APPLICANT'S NAME (Last)
duPlantier Rory B. DUP02148180
EMPLOYMENT HISTORY (Continued)
FROM (MM/DD/YY) TO (MM/DD/YY) TITLE/JOB CLASSIFICATION (Include Range or Level, if applicable) SUPERVISOR NAME
08/05/1991 03/01/2007 Andy Trujillo
EMT/911 Responder Emp#2815
HOURS PER WEEK COMPANY/STATE AGENCY NAME SUPERVISOR PHONE NUMBER
TOTAL WORKED (Years/Months)
45+ 15yrs.7mo. American Medical Response
SALARY EARNED ADDRESS
5257 Vincent av. Irwindale,CA 91706
$ 14.00 hour
PER
DUTIES PERFORMED
Los Angeles County Fire Dept. Medical Technician.Responsible for emergent triage,treatment and transport of the sick and injured.ALS/BLS
procedures per DHS guidelines.Vehicle extrication,spinal immobilization,oxygen therapy,IV set up,respiratory treatment's,basic splinting,wound
care.LA County Dept.of Mental Health Psychiatric Emergency Team response's.Patient pursuit,restraint and monitoring.Staging for LA County
Sheriff Dept SWAT casualty mobilization.Vital sign trending,comprehensive medical documentation of all procedure's.
REASON FOR LEAVING
Mass Lay off due to station closure
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
TOTAL WORKED (Years/Months)
SALARY EARNED ADDRESS
$ PER
DUTIES PERFORMED
REASON FOR LEAVING
FROM (MM/DD/YY) TO (MM/DD/YY) TITLE/JOB CLASSIFICATION (Include Range or Level, if applicable) SUPERVISOR NAME
COMPANY/STATE AGENCY NAME
HOURS PER WEEK SUPERVISOR PHONE NUMBER
TOTAL WORKED (Years/Months)
ADDRESS
SALARY EARNED
$ PER
DUTIES PERFORMED
REASON FOR LEAVING
STATE OF CALIFORNIA STATE PERSONNEL BOARD
EXAMINATION/EMPLOYMENT APPLICATION
STD. 678 (REV. 6/2010) Page 4
(First) (M.I.) EASY ID
APPLICANT'S NAME (Last)
duPlantier Rory B. DUP02148180
EMPLOYMENT HISTORY (Continued)
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
TOTAL WORKED (Years/Months)
ADDRESS
SALARY EARNED
$ PER
DUTIES PERFORMED
REASON FOR LEAVING
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
TOTAL WORKED (Years/Months) SUPERVISOR PHONE NUMBER
ADDRESS
SALARY EARNED
$ PER
DUTIES PERFORMED
REASON FOR LEAVING
FROM (MM/DD/YY) TO (MM/DD/YY) TITLE/JOB CLASSIFICATION (Include Range or Level, if applicable) SUPERVISOR NAME
COMPANY/STATE AGENCY NAME
HOURS PER WEEK SUPERVISOR PHONE NUMBER
TOTAL WORKED (Years/Months)
ADDRESS
SALARY EARNED
$ PER
DUTIES PERFORMED
REASON FOR LEAVING
STATE OF CALIFORNIA STATE PERSONNEL BOARD
EXAMINATION/EMPLOYMENT APPLICATION
STD. 678 (REV. 6/2010) Page 5
EQUAL EMPLOYMENT OPPORTUNITY
(For Examination Use Only)
APPLICANT: To assist the State of California in its commitment to Equal Employment Opportunity, applicants are asked to
voluntarily provide the following information. This questionnaire will be separated from the application prior to the examination and
will not be used in any employment decisions. Government Code Section 19705 authorizes the State Personnel Board to retain
this information for research and statistical purposes.
APPLICANT IDENTIFICATION NUMBER (EASY ID) EASY ID
FIRST 3 LETTERS OF LAST 4 DIGITS OF SOCIAL
0 2
DUP 1 4 8 1 8 0
DAY OF BIRTH DUP02148180
MONTH OF BIRTH
LAST NAME AT BIRTH SECURITY NUMBER
GENDER
AGE
(1) UNDER 21 (3) 21 - 39 (6) 40 - 69 (7) 70 AND OVER MALE FEMALE
Ethnic Category (Please check the box that best describes your race/ethnicity.):
(7)
AMERICAN INDIAN OR ALASKAN NATIVE Persons having origins in any of the tribal peoples of North America, and who maintain cultural
identification through tribal affiliation or community recognition.
ENTER TRIBAL IDENTIFICATION OR AFFILIATION
(2)
ASIAN Persons having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent. This includes China, Japan,
and Korea.
(1)
BLACK Persons having origins in any of the black racial groups of Africa.
(8)
FILIPINO Persons having origins in any of the original peoples of the Philippine Islands.
(4)
HISPANIC Persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of race.
(6)
PACIFIC ISLANDERS Persons having origins in the Pacific Islands, such as Samoa.
(5)
WHITE Persons having origins in any of the original peoples of Europe, North Africa, or the Middle East.
Check if:
(3)
OTHER (Specify)
DISABLED A person with a disability is an individual who: (1) has a physical or mental impairment or medical condition that limits one or more life
(Y)
activities, such as walking, speaking, breathing, performing manual tasks, seeing, hearing, learning, caring for oneself or working; (2) has a record or
history of such impairment or medical condition; or (3) is regarded as having such an impairment or medical condition.
MILITARY A military veteran; a widow or widower of a veteran; or a spouse of a 100% disabled veteran.
How did you learn of this Examination?
WORD OF MOUTH INTERNET
TELEPHONE JOB LINE
ADVERTISEMENT IN EXAMINATION BULLETIN LOCATED AT
THANK YOU FOR COMPLETING THIS QUESTIONNAIRE
STATE OF CALIFORNIA - STATE PERSONNEL BOARD
EXAMINATION/EMPLOYMENT APPLICATION
STD. 678 (REV. 6/2010) Page 6
INSTRUCTIONS
Read the following instructions carefully before completing this Application. Please complete the Application on a typewriter or personal
computer or print in ink. All questions must be answered completely and accurately, except as noted. You may be disqualified for any
false or misleading statements or for omitting information. The information you furnish will be used to determine your eligibility and/or
may be the basis for arriving at your final rating in an examination. During the course of an examination, you may be requested to provide
additional information regarding your qualifications, your preference regarding work location, shifts, etc.
Questions 8 and 9 - These questions should be answered
Easy ID - You are required to provide the following tracking
only if the examination bulletin indicates (a) a minimum or
information on the application. The first three letters of your last
maximum age requirement for eligibility; and/or (b) a California
name at birth, the month and day of your birth and the last four
Driver License requirement.
digits of your social security number. If you have already
established an Easy ID in the online system and it is different,
please provide that Easy ID. Explanations - Use this section to explain the details of any
response that requires additional information. Be thorough, and
Social Security Number - Providing this is voluntary in
attach additional sheet(s) if needed.
accordance with the Privacy Act of 1974 (PS 93-579). However, if
the Social Security Number is not provided, the department
Signature - Your signature and the date signed is required. If the
administering this examination will be unable to process your
Application is not signed, it may be rejected.
application for purposes of granting Veteran's Preference points,
Career Credits, written test waivers, or to check for eligibility in Education - You must include a complete record of your training
promotional examinations. and educational background. Please read the Requirements section
of the examination bulletin carefully for any special educational
Home/VRS/TTY Number - Provide your 10-digit home
requirements. If more space is needed, attach additional sheet(s).
telephone, Video Relay Service (VRS) phone number, or Text
Telephone (TTY) phone number.
Licenses - If the examination bulletin calls for a specific
Examination Title/Job Title - Fill in the exact title of the license, professional certificate, or membership in a professional
examination from the examination bulletin. Promotional organization, list the full name of the license, certificate or
examinations are only available to those who currently meet the organization, the license number, and the official expiration date of
criteria to apply on a promotional basis (i.e., civil service employee, the document or membership.
veteran, legislative employee, etc.). If applying for a vacant
position, enter the class title of the position/vacancy for which you Experience - You must include a complete list of your paid
are applying. and/or volunteer work experience which relates to the
qualification requirements specified on the examination
Question 2 - Reasonable Accommodation will be provided to
bulletin. List all relevant jobs, during the past 10 years, regardless
applicants who need assistance to take an interview or written test.
of duration, including part-time and military service. You should
If you check “Yes” you will be contacted via telephone or mail to
also list volunteer experience and jobs held more than ten years
make specific arrangements.
ago if they relate directly to the job for which you are applying.
Question 5 - Employment History/Discharges. Question 5 must State employees must list the specific departments for which
be answered by all applicants. You must answer “Yes” if you have they worked and indicate the specific civil service class title(s)
ever, because of poor performance or misconduct, been fired, held.
dismissed, or terminated from a job, or had an employment contract
terminated. Explain any “Yes” answers in the Explanations section. Examinations Granting Veteran’s Preference Points - If you
Include the facts in brief, the grounds for any action taken against have not previously applied for and been approved Veteran’s
you, and the circumstances under which you left the position. Points, you must apply for the points by completing and submitting
the Application for Veteran’s Preference Form SPB-1093 to the
In completing this application, you do not need to answer “Yes” to
State Personnel Board.
Question 5 if:
• you have been rejected during a probationary period; or NOTE: Your completed Application and other examination related
• your employer withdrew the firing, dismissal, termination, information submitted to the department administering this
or contract termination (either voluntarily or as part of a examination becomes confidential information and the property of
settlement); or the State of California as provided by Government Code Section
18934. This Application and other confidential information will
• a court or administrative agency overturned or revoked the
not be returned; therefore, we recommend that you keep a copy
firing, dismissal, termination, or contract termination.
of your completed Application for your personal records. Your
If asked about past employment history by a prospective employer rights to inspect your examination papers are set forth in Sections
during the hiring process or probationary period, however, 186-189 of Title 2 of the California Code of Regulations, which
can be accessed on the State Personnel Board’s website at
applicants are required to tell the truth regarding any firing,
www.spb.ca.gov.
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 on the Employment History
section of the application.
PLEASE ENTER YOUR NAME ON PAGES 1 THROUGH 4 AND STAPLE ALL PAGES OF THE APPLICATION
TOGETHER BEFORE SUBMITTING!
Contact this candidate