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Internship/Volunteer Application
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Steps
1.
Step One
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2.
Step Two
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3.
Step Three
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4.
Step Four
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5.
Step Five
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6.
Step Six
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Step One
PERSONAL
First Name
Middle Name
Last Name
DOB:
Address1
Address2
City
State
Zip
Phone Number
Email
College Course Requiring Internship
Intern Hours Required by College
AVAILIBILITY
Check each box you are available (including evenings). Typical work hours are 8:00am-4:30pm, Monday-Friday.
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Continue
Step Two
EMPLOYMENT HISTORY
Please list your last two employers beginning with the most recent.
Employer Name and Address
Employer Telephone
Name of Supervisor
Dates of Employment
Job Title
May we contact this employer?
-- Select One --
Yes
No
Decription of Duties
Reason for leaving
Employer Name and Address
Employer Telephone
Name of Supervisor
Dates of Employment
Job Title
May we contact this employer?
-- Select One --
Yes
No
Decription of Duties
Reason for leaving
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Step Three
EDUCATIONAL HISTORY
High School Name and Location
Degree/Graduation Date/Years completed
College School Name and Location
Areas of Major and Minor
Degree/Graduation Date/Years completed
Graduate School or Other Post-Graduate Education
Areas of Study
Degree/Graduation Date/Years completed
Other Training/Courses/Certificates
Year completed
VOLUNTEER EXPERIENCE
Agency/Organization and Address
Telephone
Name of Supervisor
Dates Volunteered
May we contact this agency?
-- Select One --
Yes
No
Responsibilities/Duties
Reason for leaving
Agency/Organization and Address
Telephone
Name of Supervisor
Dates Volunteered
May we contact this agency?
-- Select One --
Yes
No
Responsibilities/Duties
Reason for leaving
Attach additional sheets if necessary.
INTERNS ONLY
University Name
School Address
Internship Advisor
Advisor's Phone
Current GPA
Internship Credits
Areas of Interest
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Step Four
BACKGROUND
Do you have a valid Driver's License?
Yes
No
If yes, state and license number:
Do you have a car available?
Yes
No
If yes, name of insurance company:
Do you have any physical or mental condition(s) which would limit your ability to participate in activities with Waseca County Court Services?
Yes
No
If yes, please explain:
(A physical or mental condition(s) does not disqualify an intern. This data is required to determine hot to accommodate any special needs.)
Have you ever been convicted of a criminal offense (including petty misdemeanors) or major traffic offense (misdemeanor or greater)?
Yes
No
If yes, what was your offense? Include date convicted and End date of probation/parole or Court jurisdiction.
(Report all convictions past and present. Convictons may not automatically disqualify you).
Are you now or have you ever been placed on probation or participated in a diversion program?
Yes
No
If yes, please explain:
Are you currently involved in a Court matter in Minnesota or any other jurisdiction?
Yes
No
If yes, please explain:
Do you have any close friends or family members under any type of Court jurisdiction, and/or in any correctional/placement/institution/facility?
Yes
No
This will not disqualify you.
If yes, list name(s) and relationships:
Are you now or have you ever been involved with child protection or social services authorities in Waseca County or any other jurisdiction?
Yes
No
If yes, list dates and circumstances:
List where you have lived in the past five (5) years:
Have you ever been asked to resign or been terminated by an employer or an intern training program?
Yes
No
If yes, please explain:
Record checks will be done on all applicants. A conviction does not disqualify an intern. It is generally necessary for a person to have made a satisfactory community adjustment for at least one year and/or subsequent completion of probation before acceptance is considered.
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Step Five
REFERENCES
Name
Address
Telephone
Relationship
Years Known
Name
Address
Telephone
Relationship
Years Known
Name
Address
Telephone
Relationship
Years Known
References will be checked.
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Step Six
Additional Documents
Upload any additional documents needed (Résumé, coverletter, etc).
Leave This Blank:
Receive an email copy of this form.
Email address
This field is not part of the form submission.
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