Northland College Brother Bear Internship Application

F aith in A ction 400 C happle A ve., A shland, W I 54806 Phone: 715-682-4414 ext. 3 or 1-888-682-7672 F ax:715-682-5323 E mail: F iaV olunteer@A shlandA ging.org

Northland College – Brother Bear Internship Application Please attach a resume to this application. You may attach additional information on a separate sheet in completing this application, if needed.

Today’s Date______Name ______Campus Address : Address______City/State/Zip______Permanent Address: Address______City/State/Zip______Phone Number: ______Email Address:______Year of study at Northland: ___Fr ___So ___Jr ___Sr Major field of study______Anticipated date of Graduation:______Are you available 8-10 hours a week for this internship?______

Times I am available for this internship

Monday Tuesday Wednesday Thursday Friday Morning Afternoon

Why are you interested in this internship? ______List any skills you have or class you have taken which are related to this internship position. (i.e. volunteer experience, computer skills, social media skills, non-profit, work with the elderly, etc.) ______

1 ______

SCREENING INFORMATION Faith In Action-Ashland County takes seriously its obligation to provide a safe environment for all those involved in its activities. FIA will conduct a Wisconsin Department of Justice records check on all applicants. We also request the names of personal references. Personal References: Please list two references –Professional relationships such as teachers, supervisors, employers, coaches, pastors, etc. Do not use family members or friends for references.

Name ______Relationship to you: ______Address

(Street) (City) (State) (Zip Code) (PHONE NUMBER) Name ______Relationship to you: ______

(Street) (City) (State) (Zip Code) (PHONE NUMBER)

Background Information Disclosure 1) Do you have criminal charges pending against you?  Yes  No

If yes, please explain: ______2) Were you ever convicted of any crime anywhere, including in federal, state, local or military and tribal courts? (include traffic violations)  Yes  No

If yes, please explain: ______3) Were you ever convicted of any ordinance violation involving shoplifting, theft, damage to property,etc.  Yes  No

If yes, please explain: ______

4) Are you registered with Wisconsin Corrections Services/Probation and Parole? Yes  No

5) Were you ever known by any other names (including married or maiden names)  Yes  No

If yes, what names have you used?______

I understand under penalty of law, that the information provided is truthful and accurate to the best of my knowledge. I also understand the screening requirements mentioned above, and authorize Faith in Action-Ashland County to process the paperwork for the criminal background check and to contact any of my personal reference.

(Applicant signature) (Date) 2 3