Addendum to Application
ADDENDUM TO APPLICATION
Social Workers
Upload the completed addendum form as an attachment to the online application or submit completed form by mail or fax and submit official academic transcripts by mail.
FOR DEPARTMENT OF SOCIAL SERVICES, DSS, POSITIONS ONLY TO:
Mecklenburg County Department of Social Services
Attention: Human Resources
301 Billingsley Road
Charlotte, NC 28211
Or by fax to:
877-235-9684
FOR COMMUNITY SUPPORT SERVICES, CSS, POSITIONS ONLY TO:
Mecklenburg County Community Support Services
700 North Tryon St. Suite. 206
Charlotte, NC 28202
Or by fax to:
704-336-4198
Date _______________
Name ______________________________
Address________________________________________
City ______________________________ State__________ Zip_______________
Phone ______________________________________________________________________
Email _________________________________________
POSITIONS APPLIED FOR (Job Title and ID number):
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
List and describe (below) all related Social Worker positions. For each position, list the duties performed and the percentage of time each month you performed this duty.
Name of Employer #1________________________________________
Position Held________________________________________
Were you an hourly or salaried employee?__________
From_______________ To _______________
Length of Full Time Service (yrs/mths)___/___
From_______________ To _______________
Length of Part Time Service (yrs/mths)___/___
List Duties and % of time performed each month (must total 100%)
Position #1
Duty___________________________________ % of time performed each month__________
Duty___________________________________ % of time performed each month__________
Duty___________________________________ % of time performed each month__________
Duty___________________________________ % of time performed each month__________
Duty___________________________________ % of time performed each month__________
Name of Employer #2________________________________________
Position Held________________________________________
Were you an hourly or salaried employee?__________
From_______________ To _______________
Length of Full Time Service (yrs/mths)___/___
From_______________ To _______________
Length of Part Time Service (yrs/mths)___/___
List Duties and % of time performed each month (must total 100%)
Position #2
Duty___________________________________ % of time performed each month__________
Duty___________________________________ % of time performed each month__________
Duty___________________________________ % of time performed each month__________
Duty___________________________________ % of time performed each month__________
Duty___________________________________ % of time performed each month__________
Name of Employer #3________________________________________
Position Held________________________________________
Were you an hourly or salaried employee?__________
From_______________ To _______________
Length of Full Time Service (yrs/mths)___/___
From_______________ To _______________
Length of Part Time Service (yrs/mths)___/___
List Duties and % of time performed each month (must total 100%)
Position #3
Duty___________________________________ % of time performed each month__________
Duty___________________________________ % of time performed each month__________
Duty___________________________________ % of time performed each month__________
Duty___________________________________ % of time performed each month__________
Duty___________________________________ % of time performed each month__________
Name of Employer #4________________________________________
Position Held________________________________________
Were you an hourly or salaried employee?__________
From_______________ To _______________
Length of Full Time Service (yrs/mths)___/___
From_______________ To _______________
Length of Part Time Service (yrs/mths)___/___
List Duties and % of time performed each month (must total 100%)
Position #4
Duty___________________________________ % of time performed each month__________
Duty___________________________________ % of time performed each month__________
Duty___________________________________ % of time performed each month__________
Duty___________________________________ % of time performed each month__________
Duty___________________________________ % of time performed each month__________
Name of Employer #5________________________________________
Position Held________________________________________
Were you an hourly or salaried employee?__________
From_______________ To _______________
Length of Full Time Service (yrs/mths)___/___
From_______________ To _______________
Length of Part Time Service (yrs/mths)___/___
List Duties and % of time performed each month (must total 100%)
Position #5
Duty___________________________________ % of time performed each month__________
Duty___________________________________ % of time performed each month__________
Duty___________________________________ % of time performed each month__________
Duty___________________________________ % of time performed each month__________
Duty___________________________________ % of time performed each month__________
If Bachelor’s/Master’s degree is in related field please list 15 hours of Social Work/Counseling courses.
______________________________ ______________________________
______________________________ ______________________________
______________________________ ______________________________
______________________________ ______________________________
______________________________ ______________________________
______________________________ ______________________________
Revised 10/25/2012
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