SPECIALIST APPLICATION |
Return to: |
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| Date | Social Security # | ||
| Name (Last/First/Middle) | |||
| Address (Street/City/State/Zip) | |||
| Home Phone | Phone number during the day | ||
| Birth Place (optional) | Date of Birth (optional) | ||
| Position(s) for which you are applying | |||
| Have you ever been convicted of a felony? | YES |
NO | If yes, please explain: |
| EDUCATIONAL PREPARATION (List most current education first) | |||||
Inclusive Dates |
Name & Address of School |
Degree |
Credits Earned |
Major/Minor |
Date of Graduation |
| EXPERIENCE WORKING WITH / OVERSEEING YOUTH GROUPS | ||||
Title |
Name & Address of Employer |
Dates |
Supervisor / Director & Phone Number
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Length of Service |
| OTHER WORK EXPERIENCE | |||
Dates of Employment |
Employer's Name & Address |
Type of Work & Position Held Full or Part-time |
Telephone Number |
| REFERENCES (If available, a college placement bureau file is preferable over individual references) | |||
| Name |
Address |
Position / Business |
Telephone |
| ADDITIONAL INFORMATION (List any other information which will assist us in reaching a true estimate of your qualifications) |
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AFFIRMATION: I certify that all statements made in this application are true and correct, and that any misstatement of material facts may subject me to disqualification or dismissal. Also, I authorize investigation of all statements made in this application. Signature: _____________________________________________________________________________________ Date: |