PROFESSIONAL MEMBERSHIPS If more than 4, combine multiples in 1 box. Dates of Organization Name Organization’s Focus/Mission Membership If more than 4, please list additional here. EMPLOYMENT--CURRENT Primary Employer Name Dates with Employer Current Position or Title Employer Address City State ZIP Type of Setting Academic Institution Military Setting Non-profit Agency Government--Federal Private Industry Government--Local, State Private Practice Home Health Agency Rehab Facility Long-term Care Facility/SNF School System Hospital Setting Other ____________________ (please specify): Clients Served Please identify the populations served at this setting on which this application is based.
PROFESSIONAL MEMBERSHIPS If more than 4, combine multiples in 1 box. Organization Name Organization’s Focus/Mission Dates of Membership If more than 4, please list additional here. EMPLOYMENT--CURRENT Primary Employer Name Dates with Employer Current Position or Title Employer Address City State ZIP Type of Setting Academic Institution Setting Government--Federal Government--Local, State Home Health Agency Long-term Care Facility/SNF Hospital Setting Military Non-profit Agency Private Industry Private Practice Rehab Facility School System Other (please specify): ____________________ Clients Served Please identify the populations served at this setting on which this application is based.
SCEM-OT-Part-1-APPLICATION.docx