Crider Health Center

Crider Center For Mental Health

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First Name:	MI		Last Name:
SSN:			Email:
Address:			City:
State:			Zip:
Daytime Phone #			Evening Phone #

Identify the specific position(s) that are posted for which you consider yourself to be qualified:


Availability:	Full Time Part Time PRN Temporary

Have you been employed by Crider Center in the past?
	Yes No

If yes, identify the position, approximate dates of employment, and state your name while employed if different from your present name:


Have you ever been convicted of a felony?
	Yes No

Note: A "Yes" answer will not automatically disqualify you from employment. If yes, please explain fully:


Skills: If applicable to the position for which application is made, please indicate any of the following with which you have had direct experience:
	PC/CRT Typing		Words Per Minute
	Electric Typewriter		Words Per Minute
	Computer Data Entry
	Fax
	Windows Based Software
	10-Key Calculator
	Copier
Other Skills:


Describe any specialized training, internships, skills and extra-curricular activities.


List professional, trade, business or civic activities and offices held. (You may exclude membership which would reveal gender, race, religion, national origin, age, ancestry, disability or other protected status)


Please list other skills you possess which are relevant to the position for which you are applying.


Education:	GED/High School		School Name / Major
	Associate's		Associate's
	Bachelor's		Bachelor's
	Master's		Master's
	Ph.D		Ph.D
	M.D.		M.D.

Name of License(s) and Number(s):


Name of Certificate(s) and Expiration:


Have you received other training relevant to the position for which you are applying?
	Yes No
If Yes, describe:


Employment Experience: Starting with your present or most recent job, list all previous positions held. Include any military service assignments or volunteer activities (optional). You may exclude organization names which indicate race, color, religion, age, gender, national origin, disability, or other protected status.

Job #1
Employer:
Address:
Phone:
Job Title:
Supervisor:
Reason for Leaving:
Dates Employed:	From:	To:
Hourly Rate/Salary:	Starting:	Final:

Work Performed:


May we contact?	Yes No


Job #2
Employer:
Address:
Phone:
Job Title:
Supervisor:
Reason for Leaving:
Dates Employed:	From:	To:
Hourly Rate/Salary:	Starting:	Final:

Work Performed:


May we contact?	Yes No

Job #3
Employer:
Address:
Phone:
Job Title:
Supervisor:
Reason for Leaving:
Dates Employed:	From:	To:
Hourly Rate/Salary:	Starting:	Final:

Work Performed:


May we contact?	Yes No

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Mental Health Emergency Services - If you are having a mental health emergency, (for example you feel like hurting yourself or someone else) please call BHR (Behavioral Health Response) 24-hour hotline immediately at (314) 469-6644 or 1-800-811-4760 for TTY call (314) 469-3638. Administrative Login Copyright © 2008 Crider Center. All Rights Reserved. Please read our privacy policy Web Site Design By: Tracker Designs, LLC