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.

______________________________ ______________________________

______________________________ ______________________________

______________________________ ______________________________

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______________________________ ______________________________

______________________________ ______________________________

Revised 10/25/2012

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