Please use this space to elaborate on any background, experience, or qualifications that you believe should be considered in evaluating your qualifications for employment. You may include volunteer experience and other activities you believe relevant. Please omit any information that would disclose your race, gender, age, marital status, ethnic origin, religious or political affiliations, or disability. PROFESSIONAL LICENSURE/CERTIFICATION Please list all current licensure and/or certifications. Type Certifying Organization Current Licensure Are there any limitations that would affect your ability to perform the duties of the job, including loss of professional licensure/certification, limitation of privileges, or disciplinary actions? Yes No N/A If yes, please explain: Do you have current professional liability insurance? Yes No If yes, please list: REFERENCES Please list three references other than relatives. Name Name Name Position Position Position Company Company Company Relationship Relationship Relationship to to applicant to applicant applicant ____________________ Email _______________________
Please use this space to elaborate on any background, experience, or qualifications that you believe should be considered in evaluating your qualifications for employment. You may include volunteer experience and other activities you believe relevant. Please omit any information that would disclose your race, gender, age, marital status, ethnic origin, religious or political affiliations, or disability. PROFESSIONAL LICENSURE/CERTIFICATION Please list all current licensure and/or certifications. Type Certifying Organization Current Licensure Are there any limitations that would affect your ability to perform the duties of the job, including loss of professional licensure/certification, limitation of privileges, or disciplinary actions? Yes No N/A If yes, please explain: Do you have current professional liability insurance? Yes No If yes, please list: REFERENCES Please list three references other than relatives. Name Name Name Position Position Position Company Company Company Relationship to applicant Relationship to applicant Relationship to applicant ____________________ Email _______________________
chd_application.docx