Once the answers are finished, the student may go to the Work in Washington Application form and copy and paste in their answers.
YOUR CONTACT INFORMATION:
1. First Name
2. Last name
3. Telephone
4. Address
5. City
6. State
7. Emergency contact Name
8. Emergency contact Telephone
9. Name of Health Insurance Carrier
SCHOOL CONTACT INFORMATION:
10. City
11. State
12. Zip Code
13. Telephone
PERSONAL INFORMATION:
14. Date and Place of Birth
15. Are you a US Citizen?
16. If you are a naturalized citizen, please indicate the date and place you were naturalized
17. Are you a registered voter?
18. If yes, in what state?
EDUCATION:
19. Name of college or university you currently attend and indicate your expected date of graduation and degree
20. What is your current cumulative grade point average?
21. What is your current grade point average in your chosen major?
HONORS AND EXTRA CURRICULAR ACTIVITIES:
22. List any other colleges or universities you have previously attended and indicate the dates of attendance
23. List any organizations and clubs of which you have been a member during the past five years. List titles and dates of any offices you have held in each such organization
24. List any honors, prizes, or awards you have received
25. List any community services, teaching, or other civic activities not already listed
WORK EXPERIENCE:
26. List any previous work experiences (including other internships), indicate the dates you were employed and briefly describe the nature of your job
SUPPLEMENTAL INFORMATION:
27. State any additional experiences you believe would assist you in serving as an intern in Washington, DC
28. Please list three (3) individuals as references, who are familiar with your abilities and personal character. Name Address and Telephone
29. Please describe your level of proficiency with basic word processing programs (such as MS Word or WordPerfect) and your familiarity with the Internet.
30. Please list any and all assistive technologies (both hardware and software) that you employ in using computer or accessing information on the Internet.
31. Please submit a one-page (250 words) essay entitled "What personal growth I hope to gain from an internship and how it will benefit my vocational goals"
32. Have any disciplinary or administrative actions (i.e. probation suspension, expulsion) ever been taken against you by any of your schools?
33. Have you ever been charged with, or convicted of any criminal or misdemeanor offense?
34. Have you ever used, possessed, supplied or manufactured any illegal drugs?
35. If you answered "Yes" to any questions mentioned above, please explain and include the dates of actions
36. Do you use a white cane or a guide dog?
In addition, please have two references submit recommendation letters on your behalf via e-mail or U.S. Postal service. Recommendation letters sent via e-mail should be sent to both rmccaffery@tabinc.org and fbotelho@tabinc.org. Letters sent via postal service must be addressed to:
Ms. RoseMarie McCaffery
Work in Washington Program
Adaptive Solutions for Independence
110 William Street, 9th Floor
New York, NY 10038
Go back to Work in Washington Program page