Volunteer Washington Internship Program Application

Full Name
Today's Date
E-mail
Home Phone
Cell Phone
Address (home or college):
City
State
Zip Code
Extra-curricular activities:
ACADEMIC INFORMATION
College:
School Address:
Choose:	Junior Senior Graduate Student
GPA:
AVAILABILITY Please indicate your approximate start/end dates:
List the days that you are available:
List the times that you are available:
LOCATION PREFERENCE:	Olympia Spokane Vancouver
SECURITY QUESTIONS Have you had any disciplinary or administrative actions (i.e. probation, suspension, expulsion) initiated or taken against you? Yes No Have you ever been convicted of a criminal offense? Yes No If you answered “yes” to any questions above, please explain and include the dates of the actions or conclusions on a separate page (mail to: Office of the Governor, P.O. Box 40002, Olympia, WA 98504-0002 or e-mail). Your application package will not be considered complete until all documents (electronic application, resume and references, and written statement of why public service is important to you) are received.
CERTIFICATION My statements on this form, and any attachments to it, are true, complete, and correct to the best of my knowledge and belief and are made in good faith. I understand that knowingly submitting false answers will lead to the rejection of my application or immediate dismissal from the program.
	________________ _________________
	Signature Date

	Type in Name and Date

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