Retreat Center Director Position Online Application Personal DataName First Middle Last Date MM slash DD slash YYYY Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneCell PhoneE-mail Address Position Desired Full-Time Date Available MM slash DD slash YYYY Salary DesiredAble to Work Overtime? Yes No How did you learn of this opening?Are you a practicing Roman Catholic? Yes No ParishLocationHave you ever been employed by MDPRC? Yes No WhenExplinationDo you have any relatives who currently work for MDPRC? Yes No Name of relativeLocationCurrent RoleName of relativeLocationCurrent RoleAre you able to perform the essential functions of the job for which you are applying without accommodation? Yes No If you need an accommodation, what type of accommodation do you require?If hired, can you provide proof of eligibility to work in the United States? Yes No Are you a citizen of the United States? Yes No Are you competent in Microsoft Office software applications, such as Word, Excel and Powerpoint? Yes No Education & SkillsHigh School Name and LocationHigh School Number of Years AttendedHigh School MajorHigh School Degree Diploma GED None College Name and LocationCollege Number of Years AttendedCollege MajorCollege DegreeGraduate School Name and LocationGraduate School Number of Years AttendedGraduate School MajorGraduate School DegreeProfessional School/Other Name and LocationProfessional School/Other Number of Years AttendedProfessional School/Other MajorProfessional School/Other DegreeSoftware UsedOther training or skills relevant to the position you are applying forBi-lingual skills? If any, what foreign languages do you:SpeakLevel of Knowledge Fluent Intermediate Beginner ReadLevel of Knowledge Fluent Intermediate Beginner WriteLevel of Knowledge Fluent Intermediate Beginner Referred By:(Please check applicable choice and specify the source) Internet Site Employee Referral Professional Organization School Newspaper Source Name/LocationEmployment InformationAll fields are required; “see resume” is not permissible. Complete all areas even if a resume is included with your application. Start with most recent or present employer. Include part time and self-employment. Explain periods of non-employment below.Company Name*Company Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Telephone*Position/Title*Supervisor*Describe Your Duties & Responsibilities*May we contact this employer?* Yes No If no, why?*Employed From*Employed To*Full or Part Time?* Full Time Part Time Starting Salary*Ending Salary*Reason for Leaving*Company Name*Company Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Telephone*Position/Title*Supervisor*Describe Your Duties & Responsibilities*May we contact this employer?* Yes No If no, why?*Employed From*Employed To*Full or Part Time?* Full Time Part Time Starting Salary*Ending Salary*Reason for Leaving*Company Name*Company Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Telephone*Position/Title*Supervisor*Describe Your Duties & Responsibilities*May we contact this employer?* Yes No If no, why?*Employed From*Employed To*Full or Part Time?* Full Time Part Time Starting Salary*Ending Salary*Reason for Leaving*Company Name*Company Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Telephone*Position/Title*Supervisor*Describe Your Duties & Responsibilities*May we contact this employer?* Yes No If no, why?*Employed From*Employed To*Full or Part Time?* Full Time Part Time Starting Salary*Ending Salary*Reason for Leaving*Please explain periods of unemployment. (From/To)If you are applying for a position where driving is a requirement of the job, please answer the following questions:Do you have a valid driver’s license? Yes No License #Issuing StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificExp. Date MM slash DD slash YYYY Do you have a valid auto insurance? Yes No If no, why?Please read carefully and initial each statement below before signing: I understand that the Mater Dolorosa Passionist Retreat Center is a Roman Catholic religious organization and that allemployees are expected to respect and support the values, teachings and morals of the Church at all times. I certify that the information presented in this application form is true and complete. I understand that any false statements are sufficient cause for disqualification or, if hired, termination. I give the MDPRC permission to contact the references and employers listed or provided except where specificallyindicated to the contrary. I understand that MDPRC is exempt from State Unemployment and Disability programs. I understand that as a condition of employment, I must provide proof of my legal right to work in the United States in accordance with the Immigration Act of 1986. I understand this employment application is not a contract of employment and MDPRC may not hire me; if hired, I understand my employment is at will and MDPRC can terminate me at any time, with or without cause or notice. I understand employment may depend upon the results of reference checks, fingerprinting clearance, and/or physical and pre-employment tests including drug screening, VIRTUS training, and Megan's Law screening. SignatureDate MM slash DD slash YYYY
