CPBH Employment Application

CENTER FOR PEDIATRIC BEHAVIORAL HEALTH

Employment/Vonunteer Application
Attach Resume*

Cancelof
Please check which of the following you are applying for*

EmploymentVolunteerPostdoctoral FellowClinical Intern
Please check which of the following you are applying for*

Full TimePart Time

APPLICANT INFORMATION
First Name*
Last Name*
M.I.*
D.O.B.*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone*
Email*
example@example.com
Date Available*

MonthDayYear
Date
Social Security No*
Desired Salary*
State of Birth*
Desired Number of Working Hours
Position Applied for*
Have you ever been employed by the CPBH?*

YESNO
If so, what was your previous position?
From

MonthDayYear
Date
To

MonthDayYear
Date
Are you a citizen of the United States?*

YesNo
If no, are you authorized to work in the U.S.?

YESNO
Have you ever been convicted of a felony?*

YesNo
If yes, explain

EDUCATION
High School Name*
Address
From*

MonthDayYear
Date
To*

MonthDayYear
Date
Did you graduate?*

YESNO
Degree
College/ University Name*
Address*
From*

MonthDayYear
Date
Date

MonthDayYear
Date
Did you graduate?*

YESNO
Degree*
College/ University Name
Address
From

MonthDayYear
Date
To

MonthDayYear
Date
Did you graduate?

YESNO
Degree
College/ University
Address
From

MonthDayYear
Date
To

MonthDayYear
Date
Did you graduate?

YESNO
Degree

INTERNSHIP/FELLOWSHIP
Organization Name
Address
From

MonthDayYear
Date
To

MonthDayYear
Date
Did you graduate?

YESNO
Department
Organization Name
Address
From

MonthDayYear
Date
To

MonthDayYear
Date
Did you graduate?

YESNO
Department

AWARDS/SPECIAL HONORS
Award/Honors
Date Awarded

MonthDayYear
Date
Institution/Organization
Award/Honors
Date Awarded

MonthDayYear
Date
Institution/Organization
Award/Honors
Date Awarded

MonthDayYear
Date
Institution/Organization
Award/Honors
Date Awarded

MonthDayYear
Date
Institution/Organization

LICENSURE/CERTIFICATION
Licensing/Certifying Board
License/Certification Number
State
From

MonthDayYear
Date
To

MonthDayYear
Date
Licensing/Certifying Board
License/Certification Number
State
From

MonthDayYear
Date
To

MonthDayYear
Date
Licensing/Certifying Board
License/Certification Number
State
From

MonthDayYear
Date
To

MonthDayYear
Date
Licensing/Certifying Board
License/Certification Number
State
From

MonthDayYear
Date
To

MonthDayYear
Date
Additional Information

REFERENCES
Please list three professional references.
Full Name*
Relationship*
Company*
Phone*
Address
Full Name*
Relationship*
Company*
Phone*
Address
Full Name*
Relationship*
Company*
Phone*
Address

MILITARY SERVICE
Branch
From

MonthDayYear
Date
To

MonthDayYear
Date
Rank at Discharge
Type of Discharge
If other than honorable, explain.

DISCLAIMER AND SIGNATURE
I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.
Signature*

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Date*

MonthDayYear
Date
3360 Jaeckle Drive, Suite 120. Wilmington, NC, 28403

Phone: 910-660-8200

Fax: 910-660-8199

info@centerforpbh.com

www.centerforpediatricbehavioralhealth.com
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