CEDARS : Join Our Team : Internship : Internship Online Application

ALL FIELDS ARE REQUIRED TO BE CONSIDERED FOR AN INTERNSHIP! For your application to be considered, you must have all fields under the category "Practicum Information" filled out.

GENERAL

Today's Date:

Last Name:

First Name:

Middle Initial:

Current Address Street:

City:

State:

Zipcode:

Permanent Address, Street:

City:

State:

Zipcode:

Email Address:

Home Phone:

Cell Phone:

Work Phone:

Driver's License Number:

Social Security Number:

Date of Birth:

Are there any health issues or physical limitations that could affect internship work or require placement modifications:

	Yes
	No

If yes, please describe:

EDUCATION

Name of High School Attended:

High School, highest grade completed:

High School, year graduated:

Name of University/College Attended:

University/College, years completed:

Major Subjects:

Minor:

University/College, year graduated:

Name of Graduate School:

Graduate School, years completed:

Major Subjects:

Graduate School, year graduated:

Related Education/Achievements (licenses, trainings, certifications, honors):

PRACTICUM INFORMATION

Number of hours required for academic credit:

Degree in progress:

Name of University/College:

City:

Practicum Instructor:

Phone:

Email Address:

Position Applying for:

Term of Placement (check all that apply):

	Fall
	Spring
	Summer

Available Start Date (Month/Day/Year):

Anticipated End Date (Month/Day/Year):

EMPLOYMENT (List present and past employment beginning with the most recent)

Employer:

Street Address:

Position Held:

Supervisor:

Phone:

Hours Per Week:

From (Mo/Yr):

To (Mo/Yr):

Reason for Leaving:

Specific Duties:

Employer:

Street Address:

Position Held:

Supervisor:

Phone:

Hours Per Week:

From (Mo/Yr):

To (Mo/Yr):

Reason for Leaving:

Specific Duties:

Employer:

Street Address:

Position Held:

Supervisor:

Phone:

Hours Per Week:

From (Mo/Yr):

To (Mo/Yr):

Reason for Leaving:

Specific Duties:

VOLUNTEER EXPERIENCE (List present and past volunteer and military experience beginning with the most recent)

Employer:

Street Address:

Position Held:

Supervisor:

Phone:

Hours Per Week:

From (Mo/Yr):

To (Mo/Yr):

Reason for Leaving:

Specific Duties:

Employer:

Street Address:

Position Held:

Supervisor:

Phone:

Hours Per Week:

From (Mo/Yr):

To (Mo/Yr):

Reason for Leaving:

Specific Duties:

Employer:

Street Address:

Position Held:

Supervisor:

Phone:

Hours Per Week:

From (Mo/Yrs):

To (Mo/Yr):

Reason for Leaving:

Specific Duties:

PERSONAL REFERENCES (other than relatives)

Reference #1:

Phone:

Relationship:

Address:

City, State, ZIP:

Reference #2:

Phone:

Relationship:

Address:

City, State, ZIP:

Reference #3:

Phone:

Relationship:

Address:

City, State, ZIP:

Have you ever been convicted of a violation of law other than a minor traffic violation?:

	Yes
	No

If yes, please describe:

Note: a conviction record is not an automatic bar to placement. Each case is considered in relation to the position applied for.

What (if any) foreign language do you speak fluently:

DEMOGRAPHIC INFORMATION

We request your cooperation in completing the following voluntary applicant demographic information. This information will not be used in making any decision affecting employment or any personnel action following employment. It will be used to complete records required of CEDARS by governmental authorities.

Gender:

	Male
	Female

Ethnic Background:

	WHITE (not of Hispanic origin): Persons having origins in any of the original peoples of Europe, North Africa, or the Middle East.
	BLACK (not of Hispanic origin): All persons having origins in any of the black racial groups of Africa.
	HISPANIC: All persons of Mexican, Puerto Rican, Cuban, Central of South American, or other Spanish culture or origin, regardless of race.
	AMERICAN INDIAN OR ALASKAN NATIVE: All persons having origins in any of the people of North America, and who maintain cultural identification through tribal affiliation or community recognition.
	ASIAN OR PACIFIC ISLANDERS: All persons having origins in any of the original peoples of the Far East, Southeast Asia, the Indian Subcontinent or Pacific Islands. For example, China, Japan, Korea, the Philippines Islands, and Samoa.

Do you have a physical or mental disability:

	Yes
	No

If yes, please explain:

Citizenship or Immigration Status:

	U.S. Citizen
	Immigrant alien (admitted to the U.S. for lawful permanent residence) with Alien Registration Receipt form I-551
	Non-immigrant alien (admitted to the U.S. temporarily for specific purpose).

RECRUITMENT SOURCE

How did you hear about internship opportunities with CEDARS?:

	Friend/Neighbor/Relative
	Newspaper Ad
	University/College
	CEDARS Board/Staff Member
	Career/Volunteer Fair
	CEDARS Website
	Other

If other please specify:

CERTIFICATION OF APPLICANT

I certify that the information contained in this application is true to the best of my knowledge and belief. I understand that any material omission of facts or misrepresentation may result in my discharge, if placed, regardless of when discovered. Unless otherwise expressly stated in a written appointment to a position or in a written contract of employment duly approved and executed by CEDARS, interns are considered at will, and either CEDARS or the intern may terminate the relationship upon giving the proper advance notice. I grant permission to CEDARS to investigate my employment record, educational record, criminal record and other records to verify the information I have provided on this application and release CEDARS from any liability resulting from such investigation.

TYPE YOUR NAME TO CERTIFY:

Colored fields indicate required information.

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