Employment Application

Employment Experience
Start with your present or last job. Include any job-related military service assignments and volunteer activities. You may exclude organizations which indicate race, religion, ethnicity, gender, sexual orientation, age, marital status, national origin, citizenship, mental or physical disability or veteran status.
1. Name of Employer
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Job Title
Name of Supervisor
Reason for leaving
Work performed
Date started
MM slash DD slash YYYY
Date ended
MM slash DD slash YYYY
2. Name of Employer
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Job Title
Name of Supervisor
Reason for leaving
Work performed
Date started
MM slash DD slash YYYY
Date ended
MM slash DD slash YYYY
3. Name of Employer
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Job Title
Name of Supervisor
Reason for leaving
Work performed
Date started
MM slash DD slash YYYY
Date ended
MM slash DD slash YYYY
4. Name of Employer
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Job Title
Name of Supervisor
Reason for leaving
Work performed
Date started
MM slash DD slash YYYY
Date ended
MM slash DD slash YYYY

Education/Training
High School

Name and address of school
Course of study
Years completed
Diploma/Degree
Undergraduate/College

Name and address of school
Course of study
Years completed
Diploma/Degree
Graduate/Professional

Name and address of school
Course of study
Years completed
Diploma/Degree
Military Training
Untitled
Diploma/Degree
List any current professional licenses or certificates that you have.
Describe any speicalized training, apprenticeship, job-related skills acquired. Include any type of machinery, office equipment and computer skills.
List professional, trade, business or civic activities and offices held.
Please write a short essay (4-8 sentences) about what skills you bring to this job.*
Please write a short essay (4-8 sentences) on "What does mental illness mean to me?"*

Are you capable of performing in a reasonable manner, with or without a reasonable accommodation the activities involved in the job or occupation for which you have applied?
Note to applicants: Do not answer this question unless you have been informed about the requirements of the job for which you are applying.
- Yes
- No
Applicant's Statement*
- I certify that answers given herein are true and complete to the best of my knowledge.
- I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at employment decision.
- This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.
- I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment is at-will for an indefinite period unless terminated at any time by the employee or Search for Change, Inc.
- I understand that no employee or representative of the agency, other than the Chief Executive Officer, has any authority to enter into an employment contract or to change the at-will employment relationship, or to make any agreement contrary to the foregoing.
- In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of Search for Change, Inc.

Search for Change, Inc. Employment Application

Step 1 of 4

Applicant Information

Employment Experience

Education/Training