ADMIN APPLICATION

Step 1 of 5

APPLICANT INFORMATION

TODAY'S DATE(Required)

FULL LEGAL NAME(Required)

First Last

ADDRESS(Required)

Street Address City State ZIP Code

PHONE NUMBER(Required)

EMAIL(Required)

CURRENT EMPLOYMENT (AGENCY/COMPANY)(Required)

POSITION/TITLE(Required)

DEGREES HELD AND/OR EXPECTED

PLEASE LIST ANY DEGREES HELD OR EXPECTED DEGREES.(Required)

INSTITUTION

MAJOR

DEGREE

DATE

HAVE YOU EVER BEEN ASKED TO RESIGN OR BEEN TERMINATED BY A EMPLOYER?

Yes

IF YOU ANSWERED “YES,” PLEASE EXPLAIN HERE

GENERAL INFORMATION

PLEASE LIST RELEVANT PRESENT AND PAST VOLUNTEER WORK.(Required)

PROGRAM

ACTIVITIES

DATE

PLEASE LIST ANY AREAS OF COMPETENCY THAT MAKE YOU WELL EQUIPPED FOR AN ADMINISTRATIVE POSITION.(Required)

WHY DO YOU WANT TO BE AN ADMINISTRATIVE STAFF AT LDR?(Required)

HOW DID YOU LEARN OF/BECOME ACQUAINTED WITH LDR?(Required)

WHAT DO YOU EXPECT FROM THIS POSITION?(Required)

WHAT IS YOUR PREFERRED NUMBER OF HOURS?(Required)

WHAT IS YOUR PREFERRED ESTIMATED START DATE?(Required)

WHAT IS YOUR PREFERRED LOCATION?

Select all that apply.

Lakeville

St. Paul

REFERENCES

PLEASE LIST THE NAMES, AGENCY/INSTITUTIONS; AFFILIATIONS AND PHONE NUMBERS AND/OR EMAIL ADDRESSES OF THREE PEOPLE WHO ARE FAMILIAR WITH OR WHO HAVE SUPERVISED YOU WITHIN THE LAST FIVE YEARS.(Required)

NAME

AGENCY/INSTITUTION

PHONE

STATEMENT OF APPLICATION

PLEASE READ THE FOLLOWING CAREFULLY.(Required)

All information submitted by in this application is true to the best of my knowledge. I understand that any significant misstatement in, or omission from, this application may be cause for denial of appointment as an employee or cause for dismissal from the position at LDR.

By applying for an administrative position at LDR, I acknowledge that I have the responsibility to read, understand and act in accordance with all ethical and legal guidelines outlined by the organizations associated with and monitoring your license to practice, LDR employee policies and peer review procedures.

I authorize Roselyn Busscher PsyD, LP, or Michelle Frauenshuh, MA, LMFT, Co-owners of LDR to consult with persons or institutions with which I have been associated and with others, including past and present employers, who may have information bearing on my professional competence, character, and ethical qualifications. I release from liability Roselyn Busscher PsyD, LP and/or Michelle Frauenshuh MA, LMFT and LDR for acts performed in good faith and without malice in connection with evaluating my application and my credentials and qualifications. I also release from any liability all individuals and organizations who provide information to Roselyn Busscher PsyD, LP and/or Michelle Frauenshuh MA, LMFT in good faith and without malice concerning my professional competence, ethics, character, and other qualifications.

I understand and agree that I will notify LDR of any changes in my job or training status, licensure, censure or sanction by professional bodies, or any other information relating to my ability to perform my role at LDR.

By checking this box, I agree to the privacy policy.

RESUME UPLOAD(Required)

Accepted file types: pdf, txt, doc, docx, odt, ott, Max. file size: 30 MB.

ADD A COVER LETTER

Accepted file types: pdf, txt, doc, docx, odt, ott, Max. file size: 30 MB.

Phone

This field is for validation purposes and should be left unchanged.