Congressional Internship Application

CONGRESSIONAL INTERNSHIP APPLICATION U.S. Congressman Chuck Fleischmann Third District, Tennessee Please fill out the form in the space provided, sign the disclosure agreement, save it as a doc file, enclose a copy of your resume, and email it to [email protected].

Name: Phone #:

Birthday (M/D/Y): Social Security #:

Have you resided in the district? If so, how long:

Home Address:

Email:

University:

Year: Email:

Major/Minor: GPA:

High School: Year:

Prior Internship Experience: Will you receive credit for this internship: Name of Intern Coordinator: Phone Number: Where would you like to Intern? (circle one) Washington, D.C. District Days & Times of the week available for Internship: Day Monday Tuesday Wednesday Thursday Friday Time Available

List any specific dates you are unable to work during the Internship:

Computer Skills:

Short Answer Question: attach word document with your short answers 1 1. List the names of any campus organizations to which you belong, the positions you have held in each, if any:

2. List the major non-campus, civic, social, or political activities in which you have participated in the last five years. What do you consider to be your most significant contribution to these organizations? Why?

3. Describe any jobs you have held over the last five years and how these experiences would prepare you to work in Congressman Fleischmann’s office:

4. Explain why you want to be an intern for Congressman Fleischmann. What do you consider to be your major strengths and qualifications for the program? What benefits do you feel are likely to result from your participation?

5. Please list three references and include name, address, phone number, and affiliation with that person:

Below are a number of organizations, people, and publications involved in public policy. For those you recognize, place: A plus (+) in front of those you agree with on most issues, a

2 minus (-) in from of those you disagree with on most issues, a zero (0) in front of those you know, but have no strong feelings about, and leave BLANK those you do not know.

___ AFL-CIO ___ Keystone XL ___ Rand Paul ___ American Civil Pipeline ___ Ronald Reagan Liberties Union ___ Milton Friedman ___ Rush Limbaugh ___ Americans for ___ MSNBC ___ Sierra Club Democratic Action ___ Nancy Pelosi ___ Tea Party ___ Amnesty ___ National Education ___ The United Nations International Assoc ___ U.S. Chamber of ___ Brookings ___ National Commerce Institution Organization of ___ World Bank ___ CATO Institution Women ___ Common Cause ___ National Review ___ Empower America Magazine ___ English First ___ National Rifle ___ Family Research Association Council ___ National Right to ___ Fox News Work Committee ___ George W. Bush ___ North American ___ George Soros Treaty ___ Greenpeace Organization ___ Heritage Foundation

___ OSHA ___ Paul Ryan ___ Hillary Clinton ___ Planned ___ Jon Stewart Parenthood

3 By completing and signing this application for internship, I hereby certify that all information submitted is truthful. I give the Office of Rep. Chuck Fleischmann authorization to contact prior employers for references and to conduct a criminal background check. I understand that submitting false information on this application or any prior criminal offense can be grounds for denial of an internship offer, revocation of an offer, or immediate dismissal from employment.

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