EDUCATION
| Elementary | High | College/University | Graduate/Professional | |
| Name of School and Location | ||||
| Last Year Completed: (Circle) | 4 5 6 7 8 | 9 10 11 12 | 1 2 3 4 | 1 2 3 4 |
| Diploma/ Degree | XXXXXXXXXX | |||
| Describe Course of Study: |
XXXXXXXXXX | |||
| Describe Specialized Training, Apprenticeship, Skills, and Extra-Curricular Activities | ||||
List any relevant education or training regarding care of, or services to, developmentally disabled individuals. ____________________________________________________________________________
SPECIAL SKILLS AND QUALIFICATIONS (Summarize skills, qualifications acquired from employment or experience and indicate any languages you speak, read, and/or write. List professional, trade, business, or activities and offices held or completed training courses). ____________________________
______________________________________________________________________________________
Have you ever been discharged or asked to resign by any former employer? q Yes q No
If yes, explain in detail:
__________________________________________________________________
______________________________________________________________________________________
EMPLOYMENT EXPERIENCE (Start with your present or last job. Include military service and volunteer activities.)
| Employer: ___________________________ Telephone: __________________________ Address: ____________________________ Job Title: ____________________________ Supervisor: _________________________ Reason for Leaving:___________________ |
Dates Employed To: __________ From: __________ Salary Start: __________ Final: ___________ |
Work Performed ____________________________ ____________________________ ____________________________ |
| Employer: ___________________________ Telephone: __________________________ Address: ____________________________ Job Title: ____________________________ Supervisor: _________________________ Reason for Leaving:___________________ |
Dates Employed To: __________ From: __________ Salary Start: __________ Final: ___________ |
Work Performed ____________________________ ____________________________ ____________________________ |
| Employer: ___________________________ Telephone: __________________________ Address: ____________________________ Job Title: ____________________________ Supervisor: _________________________ Reason for Leaving:___________________ |
Dates Employed To: __________ From: __________ Salary Start: __________ Final: ___________ |
Work Performed ____________________________ ____________________________ ____________________________ |