US Volunteer & Internship Placement Application

Please check the box that pertains to you: / Individual / Church partner
Church name: / University partner:
University name:
Location: WR Jacksonville: Volunteer Internship
Date: / Gender: / Female Male
Last Name / First Name / Middle Name
Permanent Address
Street Address / Apartment/Unit #
City / State / ZIP Code
Phone: () / E-mail Address:
Type of Address: Home Work School Other
Date of birth (mm/dd/yy) / Country of Birth: / Citizenship(s)
Church Information
Name: / Church Address:
Pastor Name: / Phone:
Availability
Preferred length of service: weeks ORmonths (note that the minimum commitment for a World Relief internship is 2 months)
When are you available to start:
Indicate days and hours of availability (M-F):
Where did you hear of this opportunity?
OFFICE USE ONLY
Have you ever been discharged or asked to resign from any job or the military? Yes No
If yes, please specify:
Criminal Record
Have you ever been convicted of a misdemeanor or felony? Yes No If yes, please specify where and dates:
Have you ever been convicted of a sexual crime? Yes No If yes, please specify where and dates:
Employment History
Please list all work experience for the last 10 years, starting with the most recent
Position: / Company: / Dates: to
Supervisor: / Skills used:
Position: / Company: / Dates: to
Supervisor: / Skills used:
Position: / Company: / Dates: to
Supervisor: / Skills used:
References
Spiritual Reference: / Title: / Email:
Academic/Professional Reference: / Title: / Email:
Languages
Language: / 1 Elementary speaking
2 Limited word proficiency
3 Minimum professional proficiency
4 Full professional proficiency
5 Native speaking proficiency / Other Language(s) & proficiency (Indicate by number):
Other significant cross-cultural experience:
Education
Are you currently a student? Yes No If so, please list university, program of study and expected graduation date:
Levels completed: Secondary/High school GED College/University Post graduate PhD
Institution: / Dates: to / Degree/Major: / Complete? Yes No
Address:
Institution: / Dates: to / Degree/Major: / Complete? Yes No
Address:
Institution: / Dates: to / Degree/Major: / Complete? Yes No
Address:
Internship Areas of Interest and Placement
Internships
(areas of study) / Education Services - Adult & Family ESL
Health & Social Development
International Studies / International Business
Refugee Employment Services
Research & Community Development
*FOR INTERNSHIPS ONLY
School: ______
Professor and or Program Name: ______
Required units: ______