Intern Application – Human Services Inc.

Applicant Information

Name *

First

Middle

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Layout

Email *

Date Available *

Phone *

Social Security #

Position Applied For

Are you a citizen of the United States?

Yes
No

Have you ever worked for this company?

Yes
No

Have you ever been convicted of a felony?

Yes
No

If yes, please explain

Education

High School

Years Attended

Did you graduate?

Yes
No

Address

Degree

Education

College

Years Attended

Did you graduate?

Yes
No

Address

Degree

Education (copy)

Other

Years Attended

Did you graduate?

Yes
No

Address

Degree

References

Please list three professional references

Reference #1

Full Name

Company

Address

Relationship

Phone

Reference #2

Full Name

Company

Address

Relationship

Phone

Reference #3

Full Name

Company

Address

Relationship

Phone

Previous Employment

Employer 1

Company

Address

Address Line 1

City

State

Zip Code

Dates Employed

Brief Summary of Job Responsibilities

May we contact your previous supervisor for reference?

Yes
No

Phone

Supervisor

Job Title

Starting Salary

Ending Salary

Reason for Leaving

Employer 2

Company

Address

Address Line 1

City

State

Zip Code

Dates Employed

Brief Summary of Job Responsibilities

May we contact your previous supervisor for reference?

Yes
No

Phone

Supervisor

Job Title

Starting Salary

Ending Salary

Reason for Leaving

Employer 3

Company

Address

Address Line 1

City

State

Zip Code

Dates Employed

Brief Summary of Job Responsibilities

May we contact your previous supervisor for reference?

Yes
No

Phone

Supervisor

Job Title

Starting Salary

Ending Salary

Reason for Leaving

Military Service

Layout

Branch

Rank at Discharge

If other than honorable, please explain

Dates of Service

Type of Discharge

I certify that my answers are true and complete to the best of my knowledge.

If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

Signature