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:
Monday Tuesday Wednesday Thursday Friday

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