COMTREA Employment Application Form

Job Opportunity Application for External Candidates

It is the policy of COMTREA to provide equal opportunity for all qualified persons and not to discriminate against any applicant for employment because of race, religion, color, sex, age, national origin, marital or veteran status, disability or any other legally protected status. If applicable, a reasonable request for assistance in the application process may be made to the Human Resource Coordinator.

Last Name

First Name

M. I.

Email Address

Street Address

City

State

Zip Code

Date of Application

Daytime Telephone Number

Evening Telephone Number

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

	Chemical Abuse Technicians	Community Support Worker
	Clinical Secretary	Psychiatric Transcriber
	Counselor/Therapist	Clerical
	Billing/Payroll	Nurse
Other:

Availability:

	Full Time			Part Time
	PRN			Temporary

Have you been employed by COMTREA in the past?


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?


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		Lotus 123
dBase III IV		10 Key Calculator
Fax		Copier
PBX

Other:
Other spreadsheet and/or word processing software (specify nature and length of experience):
Please list other skills you possess which are relevant to the position for which you are applying:

Education:

GED/High School		Associate's
Bachelor's		Master's
Ph.D.		M.D.
Name of School(s) & Major(s)
	Associate's Degree		Bachelor's Degree
	Master's Degree		Other Degrees
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?


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:
Telephone:
Job Title:
Supervisor:
Reason for Leaving:
Dates Employed:
From:		To:
Work Performed:

Job #2:

Employer:
Address:
Telephone:
Job Title:
Supervisor:
Reason for Leaving:
Dates Employed:
From:		To:
Work Performed:

May we contact your previous employers?

Please press button only once.

Counseling for Individuals and Families Since 1974