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Eligibility requirements stipulate that registration fees must be paid as a condition of employment.

Applicant Name_____________________ Job#___________ Title__________________________

Have you ever been employed by the University of California? ____ No ____ Yes (If yes, please complete the information below.)

Name of Department: _______________________ Your Title ______________________________

Name of Immediate Supervisor: _______________ Supervisor's telephone number_______________

Duties: __________________________________________________________________________

________________________________________________________________________________

Name of Department: _______________________ Your Title ______________________________

Name of Immediate Supervisor: _______________ Supervisor's telephone number ______________

Duties: __________________________________________________________________________

________________________________________________________________________________

Any other employment or major volunteer experience ____ No ____ Yes (If yes, please complete the information below.)

Name of Company: _________________________ Your Title ______________________________

Name of Immediate Supervisor: ________________ Supervisor's telephone number ______________

Duties: __________________________________________________________________________

________________________________________________________________________________

Name of Company: ________________________ Your Title ________________________________

Name of Immediate Supervisor: _______________ Supervisor's telephone number _______________

Duties: ___________________________________________________________________________

_________________________________________________________________________________

Skills, special projects, lab techniques, etc. that are applicable to the position for which you are applying:

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

I hereby certify that all statements on this supplemental form are true and complete to the best of my knowledge. I understand that any falsification of this record or failure to disclose fully the information requested may be considered cause for separation.

SIGNATURE: ___________________________ DATE: _____________

PHONE NUMBER: ________________