BLACC_Connect_Application.html

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<h5 style="text-align:left">B.L.A.C.C. Connect Application</h5>

<header style="text-align:center;
   font-size: 45px;">
B.L.A.C.C. CONNECT | B.L.A.C.C. Corporation 
</header>

<br>
<hr>
<br>

<h4 style="text-align:center">California | Nevada | Texas | Ohio | Kansas | Florida | New York | Colorado | Washington |
Idaho | Oregon | New Mexico | Utah</h4>


<br>
<hr>
<br>

<h2 style="font-size: 25px;">1. EMPLOYEE:</h2>

<br>
<hr>
<br>

Please type or print neatly making sure all information is legible and provided as omissions will
delay processing. Please print or type and ensure all information is provided as omissions can delay processing.


<br>
<br>

<form action="mailto:blaccconnect@gmail.com" method="post" enctype="text/plain" target="_blank">


  <label for="First Name">First name:</label>
  <input type="text" id="First Name" name="First Name : "><br><br>
  
  
  <label for="Last Name">Last name:</label>
  <input type="text" id="Last Name" name="Last Name : "><br><br>
  
  
  <label for="Middle Name">Middle Name</label>
  <input type="text" id="Middle Name" name="Middle Name : "><br><br>
  
  
  <label for="Suffix Name">Suffix</label>
  <input type="text" id="Suffix Name" name="Suffix Name : "><br><br>
  
  
  <label for="Date of Birth">DOB</label>
  <input type="number" id="Date of Birth" name="Date of Birth : "><br><br>
  
  
  <label for="Title of Position">Title of Position Applied For:</label>
  <input type="text" id="Title of Position" name="Title of Position : "><br><br>
  
  
<br>
<hr>
<br>


<h2 style="font-size: 25px;">2. Gender:</h2>


<br>
<hr>
<br>


  <label for="Gender">Female/Male</label>
  <input type="text" id="Gender" name="Gender : "><br><br>
  
<h2 style="font-size: 25px;">SELF-DISCLOSURE AS AN INDIVIDUAL WITH A DISABILITY MENTAL OF PHYSICAL</h2>

<br>
<hr>
<br>


Federal and State law and District policy require that new employees be given the opportunity to
identify themselves as an individual with a disability, mentally or physically.
Do you identify as an individual with a disability?


  <label for="Disability">Yes/No</label>
  <input type="text" id="Disability" name="Disability : "><br><br>

<br>
<hr>
<br>

<h2 style="font-size: 25px;"> SELF-DISCLOSURE OF VETERAN/DISABLED VETERAN STATUS</h2>


Federal and State law and District policy require that new employees be given the opportunity to
identify themselves as veteran, or disabled veteran. If applicable, type one only:

<br>
<hr>
<br>


  <label for="Veteran Status">
    <pre>
Vietnam era veteran,
Disabled Veteran,
Other than Vietnam era,
Disabled Vietnam era veteran,
Not disabled Veteran,
Other than Vietnam era,
Not disabled,
Not a veteran
</pre>
</label>
  <input type="text" id="Veteran Status" name="Veteran Status : "><br><br>


  <label for="fname">Pick one State: 
  <pre>
  California
  Nevada
  Texas
  Ohio
  Kansas
  Florida
  New York
  Colorado
  Washington
  Idaho
  Oregon
  New Mexico
  Utah
  </pre>
  </label>
  <input type="text" id="fname" name="State : "><br><br>
  
  
  <label for="lname">Choose Only One Position (if applicable):  
  <pre>
  Mathematics
  HTML
  CSS
  Javascript
  Linux Command
  Node.js
  Cartography
  </pre>
  </label>
  <input type="text" id="lname" name="Teaching Postion : "><br><br>
  
  
  <label for="lname">Choose Only One Position: 
  
  <pre>
  State Delegate Representative
  District Coordinator Representative
  District Advisor Representative
  Field Coordinator Representative
  Field Advisor Representative
  Canvasser Representative
  Data Specialist
  Database Specialist
  Website Developer
  Website Designer
  
  </pre>
  </label>
  <input type="text" id="lname" name="B.L.A.C.C. Connect Position : "><br><br>
  

<br>
<hr>
<br>


Assignments are limited to 180 day length of service at any one time and may or may not be
renewed depending upon the needs of the District. Your assignment must be approved by the
District Office before you may start working.

Your assignment must be approved by the C.E.O. of B.L.A.C.C. Corporation before you may
start working. Employment in the Unclassified Service is “at will” which means it can be
terminated at any time for any reason or no reason at all. Although the planned period of your
employment is indicated by the dates of your assignment, such employment may be terminated
at any time. Positions in the Unclassified Service do not have a continuing right of employment.
I have read, understand, and agree to the terms of Unclassified Service employment and certify
any information I have provided is true and correct.

<br>


In regards to B.L.A.C.C. CORPORATION,   

<label for="fname">I, </label>
  <input type="text" id="fname" name="Propositions - name : "><br><br>
  
  will adhere to all rules
and guidelines due to the position I occupy within B.L.A.C.C. Connect.


  <label for="fname">I, </label>
  <input type="text" id="fname" name="Propositions - name : "><br><br>, 
  
  
  promise to follow and adhere to all rules and
guidelines to the best of my knowledge and experience. The following rules and guidelines
below,

<label for="fname">I, </label>
  <input type="text" id="fname" name="Propositions - name : "><br><br>
  
  will not violate; if during occupying the position in
B.L.A.C.C. Connect, <label for="fname">I, </label>
  <input type="text" id="fname" name="Propositions - name : "><br><br>
  
  ,violates the rules and
guidelines,

<label for="fname">I, </label>
  <input type="text" id="fname" name="Propositions - name : "><br><br>
  
  
  will resign. The following are the rules and
guidelines for confidentiality within B.L.A.C.C. CORPORATION:

<pre>

1. No sharing information about State Delegate, District Coordinator, District Advisor,
Field Coordinator, Field Advisor, Canvasser, Data Specialist, Database Specialist, Website
Developer, Website Designer, clients, investors or board members with anyone outside
the board, without proper permission from the respective B.L.A.C.C. Connect State Delegate.

2. No sharing business information in regards to B.L.A.C.C. CORPORATION financial
and business status. Unless proper forms are provided.


3. No sharing information on the developmental status of B.L.A.C.C. Connect within and
outside of B.L.A.C.C. CORPORATION.


4. Personal password/username must not be shared with anyone.
By signing the confidentiality Agreement, 

</pre>

<label for="fname">I, </label>
  <input type="text" id="fname" name="Rules And Guidelines For Confidentiality - name : "><br><br> agree to all statements, propositions, rules and guidelines depicted above.
  
  
<br>
<hr>
<br>


  <label for="fname">First name:</label>
  <input type="text" id="fname" name="Rules And Guidelines For Confidentiality - First Name : "><br><br>
  
  
  <label for="lname">Last name:</label>
  <input type="text" id="lname" name="Rules And Guidelines For Confidentiality - Last Name : "><br><br>
  
  
  <label for="lname">Middle Name</label>
  <input type="text" id="lname" name="Rules And Guidelines For Confidentiality - Middle Name : "><br><br>
  
  
  <label for="lname">Suffix</label>
  <input type="text" id="lname" name="Rules And Guidelines For Confidentiality - Sufflix Name : "><br><br>
  
  
  <label for="lname">Social Security No.</label>
  <input type="number" id="lname" name="Rules And Guidelines For Confidentiality - Social Security Number : "><br><br>
  
  
  <label for="lname">Location</label>
  <input type="text" id="lname" name="Rules And Guidelines For Confidentiality - Location : "><br><br>
  
  
<br>
<hr>
<br>


<h2 style="font-size: 25px;">2. CONVICTIONS:</h2>


<br>
<hr>
<br>


  <label for="fname">Have you ever been convicted?</label>
  <input type="text" id="fname" name="CONVICTIONS - Conviction : "><br><br>
  

<br>
<hr>
<br>

Yes, complete the required information below.
INSTRUCTIONS
In the spaces below, give complete details for every time you have been convicted as an adult
(fined, imprisoned, placed on probation, given a suspended sentence, or have forfeited bail) in
connection with any offence, in civilian or military life. If you submit incomplete information, it will
delay the processing of employment.


<br>
<hr>
<br>
Message:<br>
<textarea type="text" name="CONVICTIONS - Explanation Of Conviction : " alt="Yes/No" rows="1" cols="10">....</textarea>

<br>
<hr>
<br>


<pre><strong>
If you use penal code numbers, note that use of incorrect codes will delay the processing of
your application.

If you are in doubt, list your conviction and explain.

If available, you may attach copies of court documents that identify the specific conviction.
Do not include any conviction specified in Labor Code 432.8, which refers to various marijuana
related offenses that are more than two years old.

Do not include minor traffic violations such as parking or speeding unless you were convicted for
failure to appear for fine or sentencing.

Do not include arrests which resulted in Diversion unless you were convicted for failure to meet
the conditions of your program.

Do not include arrests that did not result in convictions, charges that have been dismissed,
sealed, expunged, or juvenile records.

</strong></pre>


<Strong>You will be fingerprinted for processing through the criminal records system. If you fail to disclose a criminal conviction or provide inaccurate information, you could forfeit employment consideration.</Strong>

<hr>


  <label for="fname">Date of Conviction (only numbers):</label>
  <input type="number" id="fname" name="CONVICTIONS - Date Of Conviction : "><br><br>
  
  
  <label for="lname">City/ State</label>
  <input type="text" id="lname" name="CONVICTIONS - City Of Conviction : "><br><br>
  
  
  <label for="lname">Disposition</label>
  <input type="text" id="lname" name="CONVICTIONS - Disposition Of Conviction : "><br><br>
  
  
  <label for="lname">Length of Time Served</label>
  <input type="text" id="lname" name="CONVICTIONS - Length of Time Served : "><br><br>
  
  
  <label for="lname">Law or Code Violation</label>
  <input type="number" id="lname" name="CONVICTIONS - Law or Code Violation : "><br><br>
  
  
  <label for="lname">Name of Institution Where Time Was Served</label>
  <input type="text" id="lname" name="CONVICTIONS - Name of Institution Where Time Was Served : "><br><br>
  
  <hr>
  <br>
(Optional)
If necessary, use additional sheets of paper: sign and date the bottom of each additional page.
Failure to account for all applicable convictions may disqualify you from employment with the
District, or if already employed, may cause you to be dismissed from employment.
I certify that this Report of Convictions is true to the best of my knowledge and belief.
<br>


<br>
<hr>
<br>
<h2 style="font-size: 25px;">Mandated Reporter Responsibilities Under The Child
Abuse And Neglect Reporting Act.</h2>


Reportable Types of Abuse and Neglect


The following condition must be reported under CNRA: Sexual abuse (including sexual assault,
sexual exploitation, pornography, and child prostitution);, general or server neglect ; physical
abuse (including crreult ior unjustifiab le punihment, unlawful corporal punishment or injury and
non-accidental physical injury ; and/or neglect in out-of-home care.

Who Reports


Mandated Reporters include the following individuals: teachers, instructional aides; teacher’s
aide; instructional assistants; classified employees of any public school; administrators or
employees of licensed community care or child day care family centers.


Who Do You Report To


Mandated Reporters are required report all incidents that pretain to the Child Abuse and Neglect
Reporting Act to the State Delegate of the respective State of B.L.A.C.C. Connect. Also a
report will be sent to the CEO of B.L.A.C.C. Corporation. Type name below if you understand your responsiblity on behalf of B.L.A.C.C. Corporation.

<br>
  
              
  <label for="fname">First Name:</label>
  <input type="text" id="fname" name="Mandated Reporter Responsibilities Under The Child
Abuse And Neglect Reporting Act - First Name : "><br><br>
  
  
  <label for="lname">Last Name:</label>
  <input type="text" id="lname" name="Mandated Reporter Responsibilities Under The Child
Abuse And Neglect Reporting Act - Last Name : "><br><br>
  
  
  <label for="lname">Middle Name</label>
  <input type="text" id="lname" name="Mandated Reporter Responsibilities Under The Child
Abuse And Neglect Reporting Act - Middle Name : "><br><br>
  
  
  <label for="lname">Suffix</label>
  <input type="text" id="lname" name="Mandated Reporter Responsibilities Under The Child
Abuse And Neglect Reporting Act - Suffix : "><br><br>
  
  
  <label for="lname">Social Security No.</label>
  <input type="number" id="lname" name="Mandated Reporter Responsibilities Under The Child
Abuse And Neglect Reporting Act - Social Security Number : "><br><br>
  
  
  <label for="lname">Location</label>
  <input type="text" id="lname" name="Mandated Reporter Responsibilities Under The Child
Abuse And Neglect Reporting Act - Location : "><br><br>
  
  
 <h2 style="font-size: 25px;"> 1. EMPLOYEE OFFICIAL ADDRESS May be a District location or PO Box. </h2>


  <label for="lname">Street Address</label>
  <input type="text" id="lname" name="EMPLOYEE OFFICIAL ADDRESS - Street Address : "><br><br>
  
  
  <label for="lname">Unit No.</label>
  <input type="text/number" id="lname" name="EMPLOYEE OFFICIAL ADDRESS  - Unit No. : "><br><br>
  
  
  <label for="lname">City</label>
  <input type="text" id="lname" name="EMPLOYEE OFFICIAL ADDRESS - City : "><br><br>
  
  
  <label for="lname">State</label>
  <input type="text" id="lname" name="EMPLOYEE OFFICIAL ADDRESS - State : "><br><br>
  
  
  <label for="lname">Zip Code</label>
  <input type="text" id="lname" name="EMPLOYEE OFFICIAL ADDRESS - Zip Code : "><br><br>
  
  
  <label for="lname">Daytime Phone</label>
  <input type="number" id="lname" name="EMPLOYEE OFFICIAL ADDRESS - Daytime Phone : "><br><br>
  
  
  <label for="lname">Evening Phone</label>
  <input type="number" id="lname" name="EMPLOYEE OFFICIAL ADDRESS - Evening Phone : "><br><br>
  
  
  <label for="lname">Cell Phone</label>
  <input type="number" id="lname" name="EMPLOYEE OFFICIAL ADDRESS - Cell Phone : "><br><br>
  
  
  <label for="lname">Email</label>
  <input type="text/number" id="lname" name="EMPLOYEE OFFICIAL ADDRESS - Email : "><br><br>
  
  
<br>
<hr>
<br>


A. RESTRICTIONS ON RELEASE OF ADDRESS / TELEPHONE
Check this box if you do not wish to have your address and telephone number released
to anyone except the organization designated as the exclusive representative for the
employee unit to which you are assigned.
B. UNEMPLOYMENT INSURANCE CLAIMS
Check this box if you wish your exclusive representative to receive your name in the
event you file for unemployment insurance benefits.


<br>
<hr>
<br>


<h2 style="font-size: 25px;">2. SALARY WARRANT / DIRECT DEPOSIT ADVISE ADDRESS:
</h2>


<br>
<hr>
<br>
  

<label for="fname">Direct Deposit / Complete B.L.A.C.C. Direct Deposit Authorization Card (Obtain from the
Secretary of B.L.A.C.C. Corporation)</label>
  <input type="text" id="fname" name="Direct Deposit : "><br><br>
  
  
<label for="fname">Mail to my official address listed above.</label>
  <input type="text" id="fname" name="Direct Deposit - Mailing Address Same Above : "><br><br>
  
  
Mail to the address listed below. (PO Box may be used here.)
<br>
<br>
<br>
<label for="fname">Mailing Address</label>
  <input type="text" id="fname" name="Direct Deposit - Mailing Address : "><br><br>
  
  
<label for="fname">Street Address</label>
  <input type="text" id="fname" name="Direct Deposit - Street Address : "><br><br>
  
  
<label for="fname">City </label>
  <input type="text" id="fname" name="Direct Deposit - City : "><br><br>
  
  
<label for="fname">State </label>
  <input type="text" id="fname" name="Direct Deposit - State : "><br><br>
  
  
<label for="fname">Zip Code</label>
  <input type="text" id="fname" name="Direct Deposit - Zip Code : "><br><br>

<br>
<hr>
<br>

<h2 style="font-size: 25px;">WARRANT RECIPIENT DESIGNATION
</h2>


<br>
<hr>
<br>
  

As provided in California Government Code § 53245, in the event of my death, I hereby
designate the following person to receive any an all warrants payable to me by B.L.A.C.C.
Corporation. This designation will remain in effect until canceled and replaced in writing. It is
also expressly understood and agreed that B.L.A.C.C. Corporation is not obligated to deliver
said warrants to the person designated above unless the designated person, within two years
after the date of said warrant or warrants, claims such warrants from the B.L.A.C.C. Corporation
and provides the District with sufficient proof of identify.


<br>
<hr>
<br>
  

<label for="fname">First Name</label>
  <input type="text" id="fname" name="WARRANT RECIPIENT DESIGNATION - First Name : "><br><br>
  
  
<label for="fname">Last Name</label>
  <input type="text" id="fname" name="WARRANT RECIPIENT DESIGNATION - Last Name : "><br><br>

<label for="fname">Relationship</label>
  <input type="text" id="fname" name="WARRANT RECIPIENT DESIGNATION - Relationship : "><br><br>
  
  
<label for="fname">Street Address</label>
  <input type="text" id="fname" name="WARRANT RECIPIENT DESIGNATION - Street Address : "><br><br>
  
  
<label for="fname">City </label>
  <input type="text" id="fname" name="WARRANT RECIPIENT DESIGNATION - City : "><br><br>
  
  
<label for="fname">State </label>
  <input type="text" id="fname" name="WARRANT RECIPIENT DESIGNATION - State : "><br><br>
  
  
<label for="fname">Zip Code</label>
  <input type="text" id="fname" name="WARRANT RECIPIENT DESIGNATION - Zip Code : "><br><br>
  
  
  <label for="lname">Daytime Phone</label>
  <input type="number" id="lname" name="WARRANT RECIPIENT DESIGNATION - Daytime Phone : "><br><br>


  <label for="fname">NAME</label>
  <input type="text" id="fname" name="Signature"><br><br>
  
  <input type="submit" value="Submit" target="_blank">
</form>

<h2 style="text-align:center;">OFFICE OF EMPLOYER EMPLOYEE RELATIONS USE ONLY </h2>
<hr>

  
<br>
Clear
<br>
Do not clear
<br>
Reviewed
<br>
Recommended by
<br>
Date:
<br>  
  
<pre>

____________________________________________________________________________________________________
Signature 									Date


</pre>

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<br>

<h4 style="text-align:left">HR Department/B.L.A.C.C. Corporation</h4><h4 style="text-align:right">B.L.A.C.C. Connect Application</h4>


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