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    Counseling Position Employment Application Form

    The Center • A Place of HOPE

    It is the policy of The Center • A Place of HOPE to recruit, hire and promote for all job classifications on the basis of merit, qualification and competence without regard to race, color, national origin, religion, sex, age or handicap. All employment decisions will be made solely upon the basis of the individual’s qualifications as related to the requirements of the position being filled.

    Please note: You are not required to furnish any information which is prohibited by federal, state, or local law.

     

    All fields required unless otherwise noted.

    Name:

    Address:

    Telephone:

    Email address:

    Position applied for:

    How were you referred to us?

    Salary desired?

    Employment desired?

    Shifts desired?

    Are you a U.S. citizen?

    Employer 1

    Firm: Kind of Business:

    Mailing Address:

    Business Phone Number:

    Employment Dates:



    Initial compensation:

    Final total compensation:

    Supervisory responsibility?



    If yes, explain:

    Name of immediate supervisor:

    Title of supervisor:

    What do (did) you like most about your job?

    What do (did) you enjoy least?

    Reasons for leaving or desire to change?

    Employer 2

    Firm: Kind of Business:

    Mailing Address:

    Business Phone Number:

    Employment Dates:

    Initial compensation:

    Final total compensation:

    Supervisory responsibility?



    If yes, explain:

    Name of immediate supervisor:

    Title of supervisor:

    What do (did) you like most about your job?

    What do (did) you enjoy least?

    Reasons for leaving or desire to change?

    Employer 3

    Firm: Kind of Business:

    Mailing Address:

    Business Phone Number:

    Employment Dates:



    Initial compensation:

    Final total compensation:

    Supervisory responsibility?



    If yes, explain:

    Name of immediate supervisor:

    Title of supervisor:

    What do (did) you like most about your job?

    What do (did) you enjoy least?

    Reasons for leaving or desire to change?

    Other Positions Held:

    Company:

    Title:

    Supervisor:

    Date started:

    Date ended:

    Initial compensation:

    Final compensation:

    Type of work:

    Reason for leaving:

    Company 2:

    Company:

    Title:

    Supervisor:

    Date started:

    Date ended:

    Initial compensation:

    Final compensation:

    Type of work:

    Reason for leaving:

    Company 3:

    Company:

    Title:

    Supervisor:

    Date started:

    Date ended:

    Initial compensation:

    Final compensation:

    Type of work:

    Reason for leaving:

    Company 4:

    Company:

    Title:

    Supervisor:

    Date started:

    Date ended:

    Initial compensation:

    Final compensation:

    Type of work:

    Reason for leaving:

    Military Experience:

    If in service please indicate branch:

    Date entered:

    Date discharged:

    Highest rank or grade:

    Terminal rank or grade:

    Nature of duties:

    Highest grade level completed

    High school:

    College/Graduate School:

    Name of High School:



    Location:



    Dates attended:

    Graduation month and year:

    Offices, honors/awards:

    College/Graduate School

    Name:

    Location:

    From:

    To:

    Major:

    Degree:

    GPA:

    Total Credit Hours:

    Extracurricular Activities, Honors and Awards:


    What undergraduate courses did you like most?


    Why?



    Other courses, seminars or studies

    Licensing/Certification

    State:



    Type:



    Number:



    Date of Issue:



    Expiration Date:

    Certification/Registration

    Type:



    Number:



    Date of Issue:



    Expiration Date:

    Has any disciplinary action been taken or is there any disciplinary action pending against you in relation to the following: License, certification, registration, membership or privileges in any institution, membership in a professional organization?



    If yes, please explain:

    Activities

    Membership in a professional or job-relevant organizations (You may exclude racial, religious and nationality groups):

    Publications, professional licenses or additional special honors or awards:

    What qualifications, abilities and strong points will help you succeed in this job?

    What are your shortcomings and areas for improvement?