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First Name *

Last Name *

Address (Home) *

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

Phone (Personal) *

Email (Personal) *

Address (Professional) *

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

Phone (Professional) *

Email (Professional) *

Highest Degree Earned as of Present: *

Bachelor's
Master's
Doctoral

Please share the area of concentration and degree earned for each of your degrees: *

Please list all of the professional credentials and certifications you hold (Example: PhD, CRC, CVE): *

We are seeking S&E Committee applications from select work settings. Please select your current work setting below: *

If you selected other, please type your work setting:

Gender *

(you may respond "prefer not to answer")

Age *

(you may respond "prefer not to answer")

Race/Ethnicity *

If you responded other, please share your self-identified race/ethnicity:

Do you wish to disclose that you have a disability? *

Yes
No
Prefer Not to Answer

If yes, please specify:

Will you require CRCC to provide any accommodations to fully participate in Committee meetings/activities? *

Yes
No

If yes, please specify:

How did you learn about the open S&E Committee position? *

Email from CRCC
CRCC Website
Referred by Colleague/Friend/Acquaintance
Other

If other, please specify:

Please select the areas of expertise in which you possess skills, knowledge, and proficiency to support the work of the CRCC S&E Commiteee *

1) Why would you like to serve on the Standards & Exam Committee? *

2) Reflecting on the ratings for Knowledge provided above, describe the strengths of each of those attributes and how would you bring those to the CRCC Standards & Exam Committee: *

3) What makes CRCC’s mission meaningful to you? *

4) Summarize your current or prior employment experience or practice responsibilities related to rehabilitation counseling and how long. (if none, briefly describe your work history): *

5) List membership(s) and/or any leadership experience in relevant national or local professional organizations or list other applicable volunteer service experience: *

6) Describe any experience working on committees in national or local professional organizations related to rehabilitation counseling: *

7) Describe if you have any exam item writing experience *

8) Is there anything of an ethical or legal nature in your background that would preclude you from discharging your duties as a Standards & Exam Committee Member? *

9) Can you share your familiarity with our application pathways? *

10) When did you last sit for the CRC Exam? Can you please share your experience? *

Resume/Vitae (2 Pages Maximum) *

Drop your file here or click here to upload

Letter of Recommendation #1 *

Drop your file here or click here to upload

Letter of Recommendation #2 *

Drop your file here or click here to upload

I have provided a copy of my current two-page (maximum) vitae/resume. *

Yes

I have provided two letters of recommendation from professional references that speak to my competencies. *

Yes

I have read the materials that were provided with regard to the Committee Member Position Description and Code of Conduct. If elected to serve, I will fulfill the duties and responsibilities of a Committee member with integrity, collegiality, and due care. Furthermore, barring any unforeseen circumstances, I am able to commit to participating in the in-person meetings indicated above for the applicable Committee, at the expense of CRCC. In addition, I am able to commit to participating on conference calls and communicating via email in order to conduct business between in-person meetings. *

Yes

I understand the S&E Committee Member position is a three (3) year commitment. *

Yes

If selected for the Standards and Exam Committee, I understand I will not be eligible to sit for the CRC Exam for five years following the expiration of my committee term. *

Yes

Signature (Please input your first and last name) *

Date (Please Type)

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