STATE OF CALIFORNIA	DEPARTMENT OF REHABILITATION

EMPLOYMENT RECORD

DR 222B (Rev. 3-91)	Page 1 of 2

INSTRUCTIONS: PLEASE COMPLETE BOTH PAGES OF THIS FORM

Careful completion of all sections of this form will help us to determine your eligibility and assist in vocational planning. In addition to employment, include trade/vocational training, special licenses, and related information. This information will be kept confidential.	Applicant/Client’s Name

Date

SECTION I EDUCATIONAL/VOCATIONAL TRAINING
Check Highest Grade Completed

1 2 3 4 5 6 7 8 9 10 11 12 GED College 1 2 3 4 5 6
TRADE, VOCATIONAL, OR PROFESSIONAL INSTITUTIONS OF HIGHER EDUCATION ATTENDED:
School

Major Courses

Certificate/Degree

School

Major Courses

Certificate/Degree

MILITARY WORK EXPERIENCE OR TRAINING:

FOREIGN LANGUAGES:

SECTION II WORK EXPERIENCE

List Last Employer First – Include Volunteer Experience
Employer

Date Began

Address: Street

City

State

Date Ended

Name of Job

Wages

Can you still do this type of work?

Yes	No	If not, why not?
Your Duties: (Describe exactly what you did. List tools and equipment used.)

Reason for leaving

What about your work did you like?

What did you dislike?

Employer

Date Began

Address: Street

City

State

Date Ended

Name of Job

Wages

Can you still do this type of work?

Yes	No	If not, why not?
Your Duties: (Describe exactly what you did. List tools and equipment used.)

Reason for leaving

What about your work did you like?

What did you dislike?

PLEASE COMPLETE BOTH PAGES OF THIS FORM

Employer

Date Began

Address: Street

City

State

Date Ended

Name of Job

Wages

Can you still do this type of work?

Yes	No	If not, why not?
Your Duties: (Describe exactly what you did. List tools and equipment used.)

Reason for leaving

What about your work did you like?

What did you dislike?

Employer

Date Began

Address: Street

City

State

Date Ended

Name of Job

Wages

Can you still do this type of work?

Yes	No	If not, why not?
Your Duties: (Describe exactly what you did. List tools and equipment used.)

Reason for leaving

What about your work did you like?

What did you dislike?

SECTION III ADDITIONAL INFORMATION
List other jobs you have had:

Of all your jobs, which did you like the best?

Of all your jobs, which did you like the least?

What do you believe you need in order to become employed?

PLEASE COMPLETE BOTH PAGES OF THIS FORM

DR 222B (Rev. 3-91)	Page 2 of 2

STATE OF CALIFORNIA

ckwhaland

2009-08-11

RCademarti

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