ADDENDUM TO APPLICATION Social Workers Upload the completed addendum form as an attachment to the online application or submit completed form by mail or fax and submit official academic transcripts by mail. FOR DEPARTMENT OF SOCIAL SERVICES, DSS, POSITIONS ONLY TO: Mecklenburg County Department of Social Services Attention: Human Resources 301 Billingsley Road Charlotte, NC 28211 Or by fax to: 704-432-0020 704-432-1001 (positions with Youth & Family Services) FOR COMMUNITY SUPPORT SERVICES, CSS, POSITIONS ONLY TO: Mecklenburg County Community Support Services 700 North Tryon St. Suite. 206 Charlotte, NC 28202 Or by fax to: 704-336-4198 Date _______________ Name ______________________________ Address________________________________________ City ______________________________ State__________ Zip_______________ Phone ______________________________________________________________________ Email _________________________________________ POSITIONS APPLIED FOR (Job Title and ID number): ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ List and describe (below) all related Social Worker positions. For each position, list the duties performed and the percentage of time each month you performed this duty. Name of Employer #1________________________________________ Position Held________________________________________ Were you an hourly or salaried employee?__________ From_______________ To _______________ Length of Full Time Service (yrs/mths)___/___ From_______________ To _______________ Length of Part Time Service (yrs/mths)___/___ List Duties and % of time performed each month (must total 100%) Position #1 Duty___________________________________ % of time performed each month__________ Duty___________________________________ % of time performed each month__________ Duty___________________________________ % of time performed each month__________ Duty___________________________________ % of time performed each month__________ Duty___________________________________ % of time performed each month__________ Name of Employer #2________________________________________ Position Held________________________________________ Were you an hourly or salaried employee?__________ From_______________ To _______________ Length of Full Time Service (yrs/mths)___/___ From_______________ To _______________ Length of Part Time Service (yrs/mths)___/___ List Duties and % of time performed each month (must total 100%) Position #2 Duty___________________________________ % of time performed each month__________ Duty___________________________________ % of time performed each month__________ Duty___________________________________ % of time performed each month__________ Duty___________________________________ % of time performed each month__________ Duty___________________________________ % of time performed each month__________ Name of Employer #3________________________________________ Position Held________________________________________ Were you an hourly or salaried employee?__________ From_______________ To _______________ Length of Full Time Service (yrs/mths)___/___ From_______________ To _______________ Length of Part Time Service (yrs/mths)___/___ List Duties and % of time performed each month (must total 100%) Position #3 Duty___________________________________ % of time performed each month__________ Duty___________________________________ % of time performed each month__________ Duty___________________________________ % of time performed each month__________ Duty___________________________________ % of time performed each month__________ Duty___________________________________ % of time performed each month__________ Name of Employer #4________________________________________ Position Held________________________________________ Were you an hourly or salaried employee?__________ From_______________ To _______________ Length of Full Time Service (yrs/mths)___/___ From_______________ To _______________ Length of Part Time Service (yrs/mths)___/___ List Duties and % of time performed each month (must total 100%) Position #4 Duty___________________________________ % of time performed each month__________ Duty___________________________________ % of time performed each month__________ Duty___________________________________ % of time performed each month__________ Duty___________________________________ % of time performed each month__________ Duty___________________________________ % of time performed each month__________ Name of Employer #5________________________________________ Position Held________________________________________ Were you an hourly or salaried employee?__________ From_______________ To _______________ Length of Full Time Service (yrs/mths)___/___ From_______________ To _______________ Length of Part Time Service (yrs/mths)___/___ List Duties and % of time performed each month (must total 100%) Position #5 Duty___________________________________ % of time performed each month__________ Duty___________________________________ % of time performed each month__________ Duty___________________________________ % of time performed each month__________ Duty___________________________________ % of time performed each month__________ Duty___________________________________ % of time performed each month__________ If Bachelor’s/Master’s degree is in related field please list 15 hours of Social Work/Counseling courses. ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ Revised 05/23/2007