Internship Application Form

Please

• Copy/paste this form into a word document
• Fill it out
• Print  and sign the form
• Scan and send via email

We look forward to hearing from you.

1.     Position No./Title:  
 
2.     Full Name
 
3.     Contact Information
 
 
 
 
 
4.     How did you learn about this program?

• Ad      
• Employee      
• Relative      
• University/School               
• Other       (please specify)

 
5.     Do you have any relatives that work for the Embassy/Consulate:    
        If yes, please list name, department where they work and how      
        long they have been employed?
 
 
 
6.     CURRENT CITIZENSHIP:
 
7.      U.S. CITIZENSHIP: Do you have any claim to U.S. Citizenship? 

• YES          
• NO

 
8.      UNIVERSITY/SCHOOL/EDUCATIONAL INSTITUTION:
 
For each institution you have attended, provide the following information in the space below. Begin with your present school and work backwards. Use continuation sheets as necessary.
Name and full address of current institution:
 
 
 
 
 
Name, title and telephone number of instructor:
 
 
 
 
Dates Attended (Month/Year).  
 
Diploma/Degree/Certificate:

• Yes       
• No

 
 
C. EXACT TITLE OF POSITION:  
 
D. NAME, TITLE AND TELEPHONE NUMBER OF IMMEDIATE SUPERVISOR:
 
 
 
 
 
E. DESCRIPTION OF WORK (Describe specific duties, responsibilities and accomplishments):
 
 
 
 
 
 
F. NUMBER OF HOURS WORKED PER WEEK: 

NUMBER OF EMPLOYEES YOU SUPERVISED:  
 
G. REASON FOR LEAVING:  
 
9.     LANGUAGES:  
 
Identify the language and indicate extent of your competence for each:  
5 = fluent 3 = good 1 = fair 0 = not at

 
 
 
 
 
10.     SPECIAL QUALIFICATIONS AND SKILLS:
 
List any special skills you possess and equipment you can use, certifications, licenses obtained, etc.
 
 
 
 
11.     TRAINING RECEIVED:
 
List any training received in areas applicable to the program in which you are applying.
 
 
 
 12.     EMPLOYMENT (if applicable):  
 
Begin with your most recent position and work backwards.
 
A. NAME AND FULL ADDRESS OF EMPLOYER:
 
 
 
 
 
B. DATES WORKED (month/day/year):   
FROM                                               TO
 
 
13.     HAVE YOU EVER WORKED FOR THE U.S. GOVERNMENT?  

• YES          
• NO

 
HAVE YOU EVER BEEN DISMISSED OR FORCED TO RESIGN FROM A POSITION?

• YES           
• NO

 
PLEASE EXPLAIN:  
 
 
 
 
 
14.     COMPUTER SKILLS
How do you rate your computer skills:
 
5 = excellent        3 = good        1 = fair         0 = none
 
List computer skills/programs in which you have experience:

 
15.     REFERENCES
 
List three persons, not related to you by blood or marriage, which are qualified to supply definite information regarding your character and suitability for the program. Do NOT include former employers (i.e., supervisors).

16. YOU MUST SIGN THIS APPLICATION. Read the following carefully before you sign.
 
- I understand that any information I give may be investigated and that a false statement may be grounds for non-consideration or dismissal of my participation in the Internship Program
- I understand that, if I am provisionally selected, an Embassy-required security certification is a prerequisite.
- I understand that, if I am provisionally selected an Embassy-required medical examination and medical certification is a prerequisite.
- I consent to the release of information about my ability and fitness for the Internship Program by employers, schools, law enforcement agencies, and other individuals and organizations to Embassy-authorized investigators and personnel.
- I certify that, to the best of my knowledge, all of my statements are true, complete and made in good faith.
- I certify that I am/will be 18 years old at the start of my internship as required by U.S. law.
- I attest that I am to continue to be or will be starting additional studies at a college, university or equivalent following this internship.
 
 
 
 
 
Signature                Date
 
 
 
 
CONTINUATION SHEET: ADDITIONAL INFORMATION (if applicable)
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17. EMPLOYMENT (if applicable): Begin with your most recent position and work backwards.
H. NAME AND FULL ADDRESS OF EMPLOYER:
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I. DATES WORKED (month/day/year): Click here to enter text. FROM Click here to enter text. TO
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J. EXACT TITLE OF POSITION: Click here to enter text.
K. NAME, TITLE AND TELEPHONE NUMBER OF IMMEDIATE SUPERVISOR:
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L. DESCRIPTION OF WORK (Describe specific duties, responsibilities and accomplishments):
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M. NUMBER OF HOURS WORKED PER WEEK: Click here to enter text. NUMBER OF EMPLOYEES YOU
Date Received: (Month/Year/Day).   
Major Field of Study: