STATE OF CALIFORNIA - CALIFORNIA DEPARTMENT OF HUMAN RESOURCES

Applications will be processed ONLY for classifications where an

EXAMINATION / EMPLOYMENT APPLICATION examination is in progress and the published final filing date has not passed,
STD. 678 (REV. 12/2017) Page 1 or for vacant positions where a department requests an application.
PRINT OR TYPE--PLEASE SEE INSTRUCTIONS ON BACK PAGE
APPLICANT IDENTIFICATION NUMBER (EASY ID)

FIRST 3 LETTERS OF Last 4 DIGITS OF SOCIAL

LAST NAME AT BIRTH MONTH OF BIRTH DAY OF BIRTH SECURITY NUMBER
APPLICANT'S NAME (Last) (First) (M.I.) SOCIAL SECURITY NUMBER

HARRIS KIZZE
MAILING ADDRESS (Number) (Street) E-MAIL ADDRESS WORK TELEPHONE NUMBER

523 LAUREL ST kizzeharris@gmail.com

(City) (County) (State) (Zip Code) HOME/VRS/TTY TELEPHONE NUMBER

VALLEJO CA 94591 (707) 803-3009

EXAMINATION(S) OR JOB TITLE(S) FOR WHICH YOU ARE APPLYING
PERSONNEL
USE ONLY
JC-155193, Primary Position: 525-554-8758-001, LICENSING-REGISTRATION EXAMINER, DEPARTMENT OF MOTOR VEHICLES

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? Yes No
3. Do your religious beliefs prevent you from taking an examination on Saturday? Yes No
4. Are you now employed by the State of California? (If "YES", fill in the information below.) Yes No
Department: Subdivision:
5. Have you ever been fired, dismissed, terminated, or had an employment contract terminated from any position for Yes No
performance or for disciplinary reasons? If "Yes", give details in the Explanations section. Refer to the instructions
for further information.
6. Have you ever entered into any written agreement with a state agency in which you agreed not to seek or accept Yes No
subsequent employment with the state or any state agency?

7. Have you ever entered into any written agreement with a state agency involving an adverse action, rejection on Yes No
probation, or AWOL termination, in which you agreed not to seek or accept subsequent employment with a particular
state agency?
8. In addition to English, list any other languages you:
a. possess verbal fluency in
b. possess written fluency in
9. I certify I can type at a speed of words per minute. (For typing applicants only.)
(ANSWER QUESTIONS 10 AND 11 ONLY IF THE EXAMINATION INDICATES THEY ARE REQUIRED.)
10. Do you meet the minimum and/or maximum age requirements? Yes No

11. Do you possess a valid California Driver License? (If "YES", fill in the information below.) Yes No

License # B7509375 Class: C Restrictions: None

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.
APPLICANT'S SIGNATURE DATE SIGNED

APPLICANTS-DO NOT USE THE SPACE BELOW-FOR PERSONNEL USE ONLY

Classes 01 02 03 04 05 06 FOR PERSONNEL USE ONLY

Flags
STATUS
WC for
Series/Levels WC
Accepted REJECTED WC
RC/Flag for
Series/Levels EXPERIENCE LICENSE REQUIREMENT

CODES EDUCATION OTHER

STAFF DATE PROCESSED

STATE OF CALIFORNIA - CALIFORNIA DEPARTMENT OF HUMAN RESOURCES

EXAMINATION / EMPLOYMENT APPLICATION

STD. 678 (REV. 12/2017) Page 2

APPLICANT'S NAME (Last) (First) (M.I.)

HARRIS KIZZE
EDUCATION
DID YOU GRADUATE FROM HIGH SCHOOL? IF NOT, DO YOU POSSESS A GED OR EQUIVALENT? IF NOT, ENTER THE HIGHEST GRADE YOU COMPLETED

Yes No Yes No

UNIVERSITY OR COLLEGE—NAME AND LOCATION, UNITS UNITS

DIPLOMA, DEGREE OR DATE
BUSINESS, CORRESPONDENCE, TRADE OR COURSE OF STUDY COMPLETED COMPLETED
CERTIFICATE OBTAINED COMPLETED
SERVICE SCHOOL SEMESTER QUARTER

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 TO

LICENSE / CERTIFICATE NUMBER ISSUE DATE
DATE SATISFY REQUIREMENTS FOR THIS EXAMINATION

EMPLOYMENT HISTORY - Begin with your most recent job. List each job separately.
FROM (MM/DD/YY) TO (MM/DD/YY) TITLE/JOB CLASSIFICATION (Include Range or Level, if applicable) SUPERVISOR NAME

05/14/2018 11/14/2018 Administrative Assistant Rachel Peterson

HOURS PER WEEK TOTAL WORKED (Years/Months) COMPANY/STATE AGENCY NAME SUPERVISOR PHONE NUMBER

40 0/5 Public Utilities Commission (___) ___-____

SALARY EARNED PER ADDRESS

No Longer Required No Longer Required 505 Van Ness, San Francisco, CA 94102
DUTIES PERFORMED

Schedules meetings, receives and organizes meeting requests, monitors upcoming meetings for compliance with ex parte filing standards.
Answers the phone and responds to incoming e-mail, escorts visitors into and out of the CPUC office. Prepares and organizes binders for the Commissioner’s
use at business and committee meetings as well as other meetings as needed, and also maintains tracking and distribution systems for internal confidential
documents, including scoping memos and proposed decisions, for the Commissioner’s review. Schedules travel for the Commissioner, including flights, hotel, and
rental car reservations. Submits travel expense claims, and files monthly travel funding authorization requests on behalf of the Commissioner.

REASON FOR LEAVING

N/A
FROM (MM/DD/YY) TO (MM/DD/YY) TITLE/JOB CLASSIFICATION (Include Range or Level, if applicable) SUPERVISOR NAME

02/02/2014 05/11/2018 Executive Secretary Marvin

HOURS PER WEEK TOTAL WORKED (Years/Months) COMPANY/STATE AGENCY NAME SUPERVISOR PHONE NUMBER

40 3/11 Compatible Technology and Security 5108122193

SALARY EARNED PER ADDRESS

No Longer Required No Longer Required

DUTIES PERFORMED

Manage and maintain calendars and schedules. Make travel arrangements. Prepare invoices, reports, memos, letters, financial statements, and other documents,
using word processing, spreadsheet, database, or presentation software. Coordinate and direct office services, such as records, departmental finances, budget
preparation, personnel issues, and housekeeping, to aid executives. Answer phone calls and direct calls to appropriate parties or take messages.

REASON FOR LEAVING

Advancement
STATE OF CALIFORNIA - CALIFORNIA DEPARTMENT OF HUMAN RESOURCES

EXAMINATION / EMPLOYMENT APPLICATION

STD. 678 (REV. 12/2017) Page 3

APPLICANT'S NAME (Last) (First) (M.I.)

HARRIS KIZZE
EMPLOYMENT HISTORY (Continued)
FROM (MM/DD/YY) TO (MM/DD/YY) TITLE/JOB CLASSIFICATION (Include Range or Level, if applicable) SUPERVISOR NAME

12/03/2007 01/02/2012 Administrative Assistant Art

HOURS PER WEEK TOTAL WORKED (Years/Months) COMPANY/STATE AGENCY NAME SUPERVISOR PHONE NUMBER

40 4/1 Regency Townhouse Property Management 7076314095

SALARY EARNED PER ADDRESS

No Longer Required No Longer Required

DUTIES PERFORMED

Accounts receivable and payables. Confirm all leases and corresponding paperwork are completed and input to software. Set up and manage paper or electronic
filing systems, recording information, updating paperwork, or maintaining documents, correspondence, or other material. Operate office equipment, such as fax
machines, copiers, or phone systems and arrange for repairs when equipment malfunctions.

REASON FOR LEAVING

Pregnancy
FROM (MM/DD/YY) TO (MM/DD/YY) TITLE/JOB CLASSIFICATION (Include Range or Level, if applicable) SUPERVISOR NAME

07/22/2005 03/11/2007 Toll Collector Diane

HOURS PER WEEK TOTAL WORKED (Years/Months) COMPANY/STATE AGENCY NAME SUPERVISOR PHONE NUMBER

40 1/7 Caltrans
SALARY EARNED PER ADDRESS

No Longer Required No Longer Required

DUTIES PERFORMED

According to vehicle classification, assesses, collects, and registers tolls in the form of cash, charge account, or ticket for all types of vehicles passing through an
assigned toll lane; makes change and prepares and issues machine-printed or handwritten charge tags and cash receipts as required; verifies the validity of
charge plates and various types of tickets, and confiscates those which are found to be invalid; watches for counterfeit, foreign, or mutilated monies; sells and
registers the sale of commute books; prepares a daily report of collections and commute book sales and inventory; may direct traffic and give information to the
public regarding points of interest and traffic directions; watches for designated vehicles or persons; may appear and testify in court in the prosecution of law
violators; enforces special rules and regulations pertinent to toll collections and the safety of property and bridge traffic; may prepare reports.

REASON FOR LEAVING

Personal Family
FROM (MM/DD/YY) TO (MM/DD/YY) TITLE/JOB CLASSIFICATION (Include Range or Level, if applicable) SUPERVISOR NAME

HOURS PER WEEK TOTAL WORKED (Years/Months) COMPANY/STATE AGENCY NAME SUPERVISOR PHONE NUMBER

SALARY EARNED PER ADDRESS

No Longer Required No Longer Required

DUTIES PERFORMED

REASON FOR LEAVING

STATE OF CALIFORNIA - CALIFORNIA DEPARTMENT OF HUMAN RESOURCES

EXAMINATION / EMPLOYMENT APPLICATION

STD. 678 (REV. 12/2017) Page 4

APPLICANT'S NAME (Last) (First) (M.I.)

HARRIS KIZZE
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 TOTAL WORKED (Years/Months) COMPANY/STATE AGENCY NAME SUPERVISOR PHONE NUMBER

SALARY EARNED PER ADDRESS

No Longer Required No Longer Required

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 TOTAL WORKED (Years/Months) COMPANY/STATE AGENCY NAME SUPERVISOR PHONE NUMBER

SALARY EARNED PER ADDRESS

No Longer Required No Longer Required

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 TOTAL WORKED (Years/Months) COMPANY/STATE AGENCY NAME SUPERVISOR PHONE NUMBER

SALARY EARNED PER ADDRESS

No Longer Required No Longer Required

DUTIES PERFORMED

REASON FOR LEAVING

STATE OF CALIFORNIA - CALIFORNIA DEPARTMENT OF HUMAN RESOURCES

EXAMINATION / EMPLOYMENT APPLICATION

STD. 678 (REV. 12/2017) Page 6

INSTRUCTIONS
Read the following instructions carefully before completing this application. Please complete the application on a 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.

Easy ID - Filling out this section is no longer required and will applicants are required to tell the truth regarding any firing,
be removed in a future version of this application. dismissal, termination, contract termination or rejection during
probationary period, whether or not the action was
Social Security Number - Providing this is voluntary in overturned, revoked, or withdrawn (either voluntarily by the
accordance with the Privacy Act of 1974 (PL 93-579). employer or, as part of a settlement agreement). Applicants
However, if the Social Security number is not provided, the are also required to provide factually correct information on
department administering this examination will be unable to the Employment History section of the application.
process your application for purposes of granting Veteran's
Preference, Career Credits, written test waivers, or to check Question 6 - Must be answered by all applicants.
for eligibility in promotional examinations and job positions. Government Code section 18720.45 requires applicants for
state employment to disclose on their application form
Telephone Number - Provide your 10-digit home, mobile, or whether they have entered into any agreement(s) with the
work telephone number. You may also provide a Video Relay state in which the applicant agreed to refrain from seeking or
Service (VRS) phone number, or Text Telephone (TTY) phone accepting any subsequent employment with the state. You
number. must answer “Yes” to this question if you have ever entered
into a written agreement with any department, agency,
Examination(s) or Job Title(s) - Fill in the exact title of the commission, board, state employer, or other governmental
examination from the examination bulletin. Promotional unit within California state civil service, where one of the
examinations are only available to those who currently meet terms of the agreement provided that you agreed not to seek
the criteria to apply on a promotional basis (i.e., state or accept subsequent employment with the state or any state
employee, veteran, legislative employee, etc.). If applying for a agency. A state agency includes any department, agency,
job position, enter the class title of the job position for which commission, board, state employer, or other governmental
you are applying. unit within the California state civil service, but does not
include the California State University.
Question 2 - Reasonable accommodation will be provided to
applicants who need assistance to take an interview or written Question 7 - Must be answered by all applicants.
test. If you check “Yes” you will be contacted via telephone or Government Code section 18720.45 requires applicants for
mail to make specific arrangements. state employment to disclose on their application form
whether they have entered into any agreement(s) with the
Question 5 - Employment History/Discharges. Question 5 state in which the applicant agreed to refrain from seeking or
must be answered by all applicants. You must answer “Yes” if accepting any subsequent employment with the state. You
you have ever, because of poor performance or misconduct, must answer “yes” to this question if you have ever entered
been fired, dismissed, or terminated from a job, or had an into a written agreement with any department, agency,
employment contract terminated. Applicants who have been commission, board, state employer, or other governmental
rejected during a probationary period, or whose dismissals or unit within the California state civil service, involving an
terminations have been overturned, withdrawn [unilaterally or adverse action, rejection on probation, or AWOL termination
as part of a settlement agreement] or revoked need not answer where one of the terms of the agreement provided that you
"Yes." Explain any “Yes” answers in the Explanations section. agreed not to seek or accept subsequent employment with a
Briefly describe the facts, findings, any action taken against particular state agency. A state agency includes any
you, and the circumstances under which you left the position. department, agency, commission, board, state employer, or
In completing this application, you do not need to answer “Yes” other governmental unit within the California state civil
to Question 5 if: service, but does not include the California State University.
• you have been rejected during a probationary period; or If you answer “Yes” to this question, please provide the name
• your employer withdrew the firing, dismissal, termination, of the particular agency and the details in the Explanations
or contract termination (either voluntarily or as part of a section.
settlement); or
• a court or administrative agency overturned or revoked Questions 10 and 11 - These questions should be answered
the firing, dismissal, termination, or contract termination. only if the examination bulletin indicates (a) a minimum or
If asked about past employment history by a prospective maximum age requirement for eligibility; and/or (b) a
employer during the hiring process or probationary period, California Driver License requirement.
STATE OF CALIFORNIA - CALIFORNIA DEPARTMENT OF HUMAN RESOURCES

EXAMINATION / EMPLOYMENT APPLICATION

STD. 678 (REV. 12/2017) Page 7

Explanations - Use this section to explain the details of which you are applying. State employees must list the
any response that requires additional information. Be specific departments for which they worked and
thorough, and attach additional sheet(s) if needed. indicate the specific civil service class title(s) held.

Applicant's Signature - Your signature and the date Equal Employment Opportunity Page - Providing this
signed is required. If the hard copy application is not signed, it information is voluntary. This data is only to be used for
may be rejected. Electronic submission of your application statistical purposes in evaluating the extent to which the
through Cal Career Account certifies your application in place of state is complying with state and federal equal
a signature and date signed. employment opportunity and non-discrimination
requirements.
Education - You must include a complete record of your
Examinations Granting Veterans' Preference - If you
training and educational background. Please read the
requirements section of the examination bulletin carefully have not previously applied and been approved for Veterans'
for any special educational requirements. If more space is Preference, you must complete and submit the Veterans'
needed, you may attach additional documentation. Preference Form, CALHR-1093 to the California Department of
Human Resources.
Licenses - If the examination bulletin requires a specific
license, professional certificate, or membership in a NOTE: Your completed application and other
professional organization, list the full name of the license, examination related information submitted to the
certificate or organization, the license number, and the department administering this examination becomes
official expiration date of the document or membership. confidential information and the property of the State of
California as provided by Government Code section
Employment History and Experience - You must 18934. This application and other confidential information
include a complete list of your paid and/or volunteer work will not be returned; therefore, it is recommend that
experience that relates to the qualification you keep a copy of your completed application for your
personal records. Your rights to inspect your examination
requirements specified on examination bulletin. List
papers are set forth in Section 186-189 of Title 2 of the
all relevant jobs, during the past 10 years, regardless of California Code of Regulations, which can be accessed
duration, including part-time and military service. You at Office of Administrative Law web site at: oal.ca.gov
should also list volunteer experience and jobs held more
than ten years ago if they relate directly to the job for

PLEASE ENTER YOUR NAME ON PAGES WHERE INDICATED

AND STAPLE ALL PAGES OF THE APPLICATION TOGETHER BEFORE SUBMITTING.