McMinnville WORKS Internship Program Coordinator Application Form

Please complete the following form to apply for the McMinnville WORKS Intern Program Coordinator position (January Term and Summer 2016 positions). Application Close is December 4 for the January position, 2016.

First Name:

Last Name:

Street Address:

City:

State:

Zip Code:

Phone Number:

Email:

Will you be 18 years of age by January 4, 2016?

	Yes
	No

Are there circumstances that would prevent you from starting work on January 4, 2016?

	Yes
	No

If Yes, please describe:

Our positions require that you be legally allowed to work in the United States. Are you? (Federal Law requires proof of identity and employment authorization for all new employees).

	Yes
	No

Please select the Internship Position that you are interested in. Check all that apply:

Have you been employed by a participating company previously? Please list:

If Yes, List the dates you were employed:

Education:

High School or GED:

Location (City, State):

Major/Minor:

# of years completed:

Degree or Diploma?

	Yes
	No

Business College or Trade School:

School Name:

Location (City, State):

Major/Minor:

# of years completed:

Degree or Diploma?

	Yes
	No

College or University:

School Name:

Location (City, State):

Major/Minor:

# of years completed:

Degree or Diploma?

	Yes
	No

Graduate School:

School Name:

Location (City, State):

Major/Minor:

# of years completed:

Degree or Diploma:

	Yes
	No

Employment:

Please provide the name of your current or most recent employer:

Address:

Position held:

Rate of pay:

Supervisor's Name:

Supervisor's Title:

Supervisor's Phone Number:

Supervisor's Email:

Dates employed:

Please list any jobs, duties, skills used or learned during your time there:

Reason for leaving:

Please list any job related education or skills (including certifications, operating equipment experience, etc.):

Please list any software programs you have used:

Are you willing and able to work 30-40 hours per week from January 4 - January 29, 2016 for the January Term Internship?

	Yes
	No

Are you willing and able to work 30-40 hours per week from June 13 - August 19, 2016 for the Summer Internship?

	Yes
	No

If No, please list dates and reason you are unable to work because of other commitments (ie: vacation, camp, class, etc.):

In the event that other internship positions are available outside of the McMinnville WORKS program would you like us to share your resume with them?

	Yes
	No

Some positions require employees to operate vehicles while on company business. Do you have a valid driver's license?

	Yes
	No

By electronically SIGNING AND DATING this application below, I acknowledge that the information I have provided is true and correct to the best of my knowledge:

Please attach Cover Letter and Resume:

Please type the characters visible on the picture below:

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McMinnville WORKS Internship Program Coordinator Application Form

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