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Name
Today's Date
Phone Number
Business Phone
Address
City
State, Zip
Email Address
DOB
INTERN INFORMATION:
Past or Present Employer Name and Address
Position Held
Position(s) for which you are applying:
Describe briefly your interest in an internship at CitiIMPACT:
Do you have the legal right to work and be employed in the U.S.?
Yes
No
Please describe the skills you are bringing to CitiIMPACT and attach a resume:
Resume (File format must be doc, docx, txt, or pdf)
List any previous intern positions
How did you learn about CitiIMPACT and its intern program?
Have you ever applied for employment or been employed by CitiIMPACT?
Yes
No
SCHOOL INFORMATION:
College or University Name:
Intern Advisor & Phone Number:
Major
Year
Fr.
S
Jr.
Sr.
Grad.
Internship required for graduation:
Yes
No
CHRISTIAN COMMITMENT:
Because of the unique nature of our ministry, we are concerned that our interns are comfortable within our Christ-centered community. We commit to maintaining our identity as Christian, while being sensitive to the diverse contexts in which we express that identity. All interns must respect CitiIMPACT Ministries’ Christian statement of faith and/or the Lausanne Covenant and abide by our policies, working within our parameters and authority.
Please answer the following questions if applicable, if not skip down to the next section:
Are you presently attending a church?
Yes
No
If yes, what is the name, address, and phone number of the church?
What is your pastor's name?
Are you involved at your church in any volunteer capacity?
Yes
No
If yes, please explain:
Please share a personal statement of your relationship with Jesus Christ.
REFERENCES:
List those familiar with your capabilities (do not list relatives).
Name, Years Known, Company/ Organization, Position, Home or Business Address, Home or Business Phone
Name, Years Known, Company/ Organization, Position, Home or Business Address, Home or Business Phone
Have you been convicted of any crimes other than traffic violations?
Yes
No
If yes, please explain:
Emergency Contact Info
Name
Relationship
Complete Address
Phone
AVAILABILITY
Date available to begin internship:
Length of internship commitment
I hereby certify that the information contained in this application form is true and correct to the best of my ability. I agree to conform to the rules and standards of the company as amended from time to time at the company’s sole discretion. I understand that I’m considering an internship for the sole purpose of completing my course requirements. I understand that this does not entitle me to employee status, wages, benefits or assure me of employment following my internship with CitiIMPACT Ministries. I understand that a stipend may or may not be offered for my internship.
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